Reasons doctors provide futile treatment at the end of life: An Australian qualitative study

Transcription

1 CRICOS No.00213J Reasons doctors provide futile treatment at the end of life: An Australian qualitative study Professor Lindy Willmott Queensland University of Technology Australia

2 The research team Prof Lindy Willmott, Australian Centre for Health Law Research Centre, QUT Prof Ben White, Australian Centre for Health Law Research Centre, QUT E/Prof Cindy Gallois, School of Psychology, UQ Prof Malcolm Parker, School of Medicine, UQ Prof Nicholas Graves, School of Public Health, QUT Dr Sarah Winch, School of Medicine, UQ Professor Leonie Callaway, RBWH and UQ Nicole Shepherd, Australian Centre for Health Law Research Centre, QUT and School of Medicine, UQ Eliana Close, Australian Centre for Health Law Research Centre, QUT

3 Research partners Royal Brisbane and Women s Hospital (RBWH) Research Partner Organisation Professor Leonie Callaway Futility Research Group Also acknowledge support of: the Princess Alexandra Hospital the Princes Charles Hospital

4 The project Futile Treatment at the End of Life: Legal, Policy, Sociological and Economic Perspectives Seeking to understand futile treatment : the concept, frequency, drivers and cost Funded by Australian Research Council and supported by RBWH (partner organisation)

5 Method Stage 1: analysis of the laws and policies that govern the provision of futile treatment Stage 2: in-depth interviews with doctors as to how they define futile treatment at the end of an adult's life, and why and how often they believe it is provided Stage 3: retrospective chart audit for deaths over a 6-month period, to examine the incidence, cost, and reasons for futile treatment

6 Stage 2 In-depth interviews Department Total Emergency 15 ICU 12 Palliative care 10 Oncology 10 Renal 9 Internal medicine 9 Respiratory 9 Surgery 8 Cardiology 5 Geriatrics 5 Medical administration 4 TOTAL 96

7 Drivers of futility Doctor-related factors (92) Patient-related factors (87) Hospital-related factors (65)

8 Doctor-related factors Doctor-related factors Drs *Trained to treat 81 *Inexperience with death and dying 42 Don t want to give up hope 38 *Aversion to death 37 Worries about legal risk 29 Poor communication 28 Doing everything possible 23 Emotional attachment to patients 19 Personality, personal experiences or religion 12

9 Doctor-related factors (cont) they're trained to treat. You don't learn - you learn how to treat and it's easy to treat. It's much easier to treat than to have those high level discussions where you talk about end of life and not treating. So the default is to keep treating.

10 Doctor-related factors (cont) you do a procedure because it can be done, even if it doesn't change the outcome. recently we did a big operation to take out most of his cancer. But because it was only most of it, it's not actually going to change anything. If we'd thought that through beforehand, we would've not done that treatment.

11 Doctor-related factors (cont) Doctor-related factors Drs Trained to treat 81 Inexperience with death and dying 42 *Don t want to give up hope 38 Aversion to death 37 Worries about legal risk 29 Poor communication 28 Doing everything possible 23 *Emotional attachment to patients 19 Personality, personal experiences or religion 12

12 Doctor-related factors (cont) if you don't have a system you can hang your hat on to say this is how we've come to this decision, this is our system, these are our guidelines, we've complied with our guidelines, we're safe then you're out there exposed. So you need courage and this isn't a system that encourages or rewards courage.

13 Doctor-related factors (cont) Doctor-related factors Drs Trained to treat 81 Inexperience with death and dying 42 Don t want to give up hope 38 Aversion to death 37 Worries about legal risk 29 *Poor communication 28 *Doing everything possible 23 Emotional attachment to patients 19 Personality, personal experiences or religion 12

14 Doctor-related factors (cont) I see it all the time. When those doctors, devout doctors, who have a strong right to life, when they are practising on their own without any integration with any other doctors, then they can go on clearly without any interference on their futile way.

15 Patient-related factors Patient-related factors Drs Family or patient request 63 Prognostic uncertainty 47 Lack of information about patient wishes 36

16 Patient-related factors (cont) Patients families often have unrealistic expectations. [The provision of futile treatment] will probably come down to how forthright or aggressive the family are and also come down to the doctor s ability to deal with that. Their confidence or their courage of conviction.

17 Hospital-related factors Hospital-related factors Drs Specialisation 27 Medical hierarchy 26 Hospital designed to provide acute care so it does 25 Hard to stop once started 22 Time pressure 18 After hours care 10

18 Strategies to avoid futile treatment 1. Communicate effectively with the patient (71) 2. Set limits on treatment (35) 3. Offer a second opinion (31) 4. Consult with colleagues (28) 5. Show or rely on clinical leadership (21)

19 Strategies to avoid futile treatment (cont) 6. Discuss cases at morbidity & mortality reviews (17) 7. *Refer to Adult (Public) Guardian (10) 8. *Escalate to hospital authorities (9) 9. Routine completion of ARPs (4) 10. Special program for RACF patients (3) 11. Good integration of palliative care (3) 12.*Consult with medico-legal department (2)

20 Systemic changes needed 1. Encourage advance care planning (44) 2. Public education campaign about the realities of dying in hospital (34) 3. Introduce policy to prevent futile treatment (31) 4. Improve medical education and ongoing training (28) Improve communication skills Diagnosing dying 5. Improve decision-making (within hospitals) (19) 6. Change the law (14) 7. Expand community based end-of-life care (8)

21 Some concluding observations Complex set of interrelated reasons why futile treatment is provided patient-related, clinician-related and institutional factors Clinician-related factors are cited more frequently than patient-related or institutional factors as drivers of futile treatment Effective communication and setting limits on treatment are cited most frequently as strategies currently used by doctors to limit futility System changes of advance care planning, public education and introducing hospital policies were suggested to limit futility

22 Willmott et al, Reasons doctors provide futile treatment at the end of life: a qualitative study (2016) 42 Journal of Medical Ethics Web: