Limiting treatment and shortening of life: data from a cross-sectional survey in Germany on frequencies, determinants and patients' involvement

Background: Limiting treatment forms part of practice in many fields of medicine. There is a scarcity of robust data from Germany. Therefore, in this paper, we report results of a survey among German physicians with a focus on frequencies, aspects of decision making and determinants of limiting treatment with expected or intended shortening of life. Methods: Postal survey among a random sample of physicians working in the area of five German state chambers of physicians using a modified version of the questionnaire of the EURELD Consortium. Information requested referred to the patients who died most recently within the last 12 months. Logistic regression was performed to analyse associations between characteristics of physicians and patients regarding limitation of treatment with expected or intended shortening of life. Results: As reported elsewhere, 734 physicians responded (response rate 36.9%) and of these, 174 (43.2%) reported a withholding and 144 (35.7%) a withdrawal of treatment. Eighty one physicians estimated that there was at least some shortening of life as a consequence. In 25.9% of these cases hastening death had been discussed with the patient at the time or immediately prior to this action. Types of treatment most frequently limited was artificial nutrition (n = 35). Bivariate analysis indicates that limitation of treatment with possible or intended shortening of life for patients aged > 75 years is performed significantly more often (p = 0.007, OR 1.848). There was significantly less limitation of treatment in patients who died from cancer compared to patients with other causes of death (p = 0.01, OR 0.486). There was no significant statistical association with physicians' religion, palliative care qualification or frequencies of limiting treatment. Conclusions: In comparison to recent research from other European countries, limitation of treatment with expected or intended shortening of life is frequently performed amongst the investigated sample. The role of clinical and non-medical aspects possibly relevant for physicians' decision about withholding or withdrawal of treatment with possible or intended shortening of life and reasons for non-involvement of patients should be explored in more detail by means of mixed method and interdisciplinary empirical-ethical analysis

Begrenzungen medizinischer Maßnahmen am Lebensende

Begrenzungen medizinischer Maßnahmen am Lebensende sind in vielen medizinischen Bereichen Teil des klinischen Alltags. In Deutschland liegen dazu kaum Daten vor. 2003 Ärzte erhielten einen Fragebogen zur Handlungspraxis am Lebensende. Anhand logistischer Regressionen wurden Assoziationen zwischen Charakteristika von Arzt bzw. Patient sowie der Begrenzung medizinischer Maßnahmen untersucht. Die Rücklaufquote betrug 36,9%. 43,2% haben einen Behandlungsverzicht und 35,7% einen Abbruch durchgeführt. Begrenzungen medizinischer Maßnahmen wurden häufiger bei ≥ 75jährigen Patienten (p=0,007, OR 1,848) und seltener bei an Krebs erkrankten Patienten (p=0,01, OR 0,486) vollzogen. Begrenzungen medizinischer Maßnahmen werden in dieser Stichprobe häufig durchgeführt. Klinische und nicht-medizinische Aspekte, die möglicherweise die ärztliche Entscheidung zur Handlungspraxis beeinflussen, sollten weiter untersucht werden

Limiting treatment and shortening of life

$\textbf {Background:}$ Limiting treatment forms part of practice in many fields of medicine. There is a scarcity of robust data from Germany. Therefore, in this paper, we report results of a survey among German physicians with a focus on frequencies, aspects of decision making and determinants of limiting treatment with expected or intended shortening of life. $\textbf {Methods:}$ Postal survey among a random sample of physicians working in the area of five German state chambersof physicians using a modified version of the questionnaire of the EURELD Consortium. Information requested referred to the patients who died most recently within the last 12 months. Logistic regression was performed to analyse associations between characteristics of physicians and patients regarding limitation of treatment with expected or intended shortening of life. $\textbf {Results:}$ As reported elsewhere, 734 physicians responded (response rate 36.9%) and of these, 174 (43.2%) reported a withholding and 144 (35.7%) a withdrawal of treatment. Eighty one physicians estimated that there was at least some shortening of life as a consequence. In 25.9% of these cases hastening death had been discussed with the patient at the time or immediately prior to this action. Types of treatment most frequently limited was artificial nutrition ($\it n$ = 35). Bivariate analysis indicates that limitation of treatment with possible or intended shortening of life for patients aged > 75 years is performed significantly more often ($\it p$ = 0.007, OR 1.848). There was significantly less limitation of treatment in patients who died from cancer compared to patients with other causes of death ($\it p$ = 0.01, OR 0.486). There was no significant statistical association with physicians’ religion, palliative care qualification or frequencies of limiting treatment. $\textbf {Conclusions:}$ In comparison to recent research from other European countries, limitation of treatment with expected or intended shortening of life is frequently performed amongst the investigated sample. The role of clinical and non-medical aspects possibly relevant for physicians’ decision about withholding or withdrawal of treatment with possible or intended shortening of life and reasons for non-involvement of patients should be explored in more detail by means of mixed method and interdisciplinary empirical-ethical analysis