Most physicians in Asia withhold life-sustaining treatment for terminally ill patients

Should doctors administer life-sustaining treatment to patients who are terminally ill? This is a question that raises much ethical debate. Now, a new study published in JAMA Internal Medicine reveals that the majority of physicians in Asia hold back from providing such treatments.

More than 70% of 1,465 physicians surveyed said they would hold back life-sustaining treatment for patients "with no real chance of recovering a meaningful life."

According to the study researchers at the National University Hospital in Singapore, more than half of all cases of critical illness, mechanical ventilation and deaths in intensive care units (ICUs) occur in Asia.

However, the researchers note there is very little data on end-of-care practices in ICUs across the continent.

The few studies that have looked at the issue have found there are large variations in such practices, which researchers believe are driven by the attitudes and religious beliefs of doctors, the involvement of patients' families, economic status of the country, legislation, culture and the organization of ICUs.

"Because these characteristics vary between and within countries," the authors note, "it may be hypothesized that substantial differences in the way physicians approach end-of-life care exist between Asia and the West, and among Asian countries and regions themselves."

Over 70% of physicians in Asia would withhold life-sustaining treatments

To find out, the researchers asked 2,460 physicians to complete a scenario-based survey designed to gather information on their attitudes toward withholding and withdrawal of life-sustaining treatments among patients in ICUs.

The physicians managed patients in 466 ICUs over 16 countries and regions in Asia, including Pakistan, China, Honk Kong, Iran, Singapore, China, Thailand, Bangladesh, Indonesia, Japan, India and the Philippines.

Of the 1,465 physicians who completed the survey, 70.2% said they would often or almost always withhold life-sustaining treatments for patients "with no real chance of recovering a meaningful life," while 20.7% said they would often or almost always withdraw life-sustaining treatments for such patients.

What is more, 2.5% of physicians said they would often or almost always intentionally administered large doses of drugs - such as barbiturates and morphine - to terminally ill patients until they passed away.

The researchers point out, however, that there were "striking differences" in results when assessed by region and country.

For example, in one scenario presented to the physicians in the survey - in which they were asked what they would do if a patient with hypoxic-ischemic encephalopathy (brain injury as a result of asphyxia) developed septic shock - all respondents from Hong Kong, Pakistan, the Philippines and Singapore said they would action a do-not-resuscitate (DNR) order, while only half of physicians from China and Iran said they would do the same.

Wishes of patients, families and surrogates are major factor in treatment decisions

When reviewing the reasons behind the physicians actions, the team found that 84.1% reported patients' wishes as an important factor in their decision to withdraw life-sustaining treatments, while 77.9% said requests from family or surrogates played a major role in their treatment decisions.

However, the researchers found that only 43.9% of physicians reported being comfortable talking about the limitation of patient care with family or surrogates, and 35.6% said patients, family or surrogates often or almost always asked for "inappropriate" life-sustaining treatment.

What is more, 74.5% of physicians said they believe withholding and withdrawing treatment for terminally ill patients are "ethically different."

The researchers say they hope their findings - which have revealed some of the factors that influence the treatment decisions of physicians in Asia toward critically ill patients - will help improve end-of-life care.

"Moving forward, more research can be done to study ICU physicians' attitudes toward palliative care collaborations in Asia.

Qualitative studies examining patients' and families' views on prolonged mechanical ventilation, withholding and withdrawal would also shed light on the complex influences affecting decision making and effective provision of end-of-life care for patients in the ICU. Subspecialty ICUs may also have differing practices that may be worthwhile to explore at a deeper qualitative level as well."

References:

1.  Withholding and withdrawal of life-sustaining treatments in intensive care units in Asia, Jason Phua, et al., JAMA Intern Med, doi:10.1001/jamainternmed.2014.7386, published online 12 January 2015, abstract.
2.  How Asia differs from the West, Mervyn Koh, Poi Choo Hwee, JAMA Intern Med, doi:10.1001/jamainternmed.2014.7397, published online 12 January 2015, editorial.