Studies reveal physicians’ attitudes on end-of-life care

Doctors appear willing to use intensive treatment to lessen otherwise untreatable pain or other severe symptoms in dying patients even if the treatment, at least in theory, risks hastening the dying process, according to two University of Iowa and Yale University studies on end-of-life care.

Known as “terminal sedation,” the practice involves the use of sedating medications to control a patient’s symptoms even if it results in decreased or complete loss of consciousness. In contrast to physician-assisted suicide, terminal sedation may risk, but does not intend, hastening or causing death. A majority of physicians in the studies drew a clear line between terminal sedation and assisted suicide. In addition, physicians’ attitudes were related to two notable factors: their experience in caring for terminally ill patients and their frequency of attending religious services.

One study, which focused on internal medicine physicians, appeared in the October issue of the Journal of Medical Ethics. The second study, which focused on internal medicine residents (doctors in training), was published in the September/October issue of the American Journal of Hospice and Palliative Medicine.

Both studies were led by Lauris Kaldjian, M.D., assistant professor of internal medicine in the UI Roy J. and Lucille A. Carver College of Medicine and member of the college’s Program in Biomedical Ethics and Medical Humanities. Kaldjian was formerly on the faculty at Yale University. “End-of-life care involves many treatment decisions, some of which are focused on extreme pain and other symptoms that are very challenging to control,” Kaldjian said. “We studied the specific ethical issues of treatments that control symptoms versus interventions that intend to cause or hasten death.”

The study of internal medicine physicians, who had been in practice for at least several years, involved 677 Connecticut members of the American College of Physicians (ACP). The study of doctors-in-training involved 236 residents in three internal medicine residency programs in Connecticut. Participants in each study responded anonymously to questions in a survey. The questions were phrased as statements, and respondents indicated their agreement or disagreement on a five-point scale, with “not sure” as a sixth option.

Among the ACP physicians, 78 percent of respondents supported the use of terminal sedation, while among the residents, 66 percent agreed with the practice. In both groups, about one-third of respondents supported physician-assisted suicide, in theory, as “ethically appropriate” in certain circumstances. The practice is legal only in Oregon, not in Connecticut or other states.

While general attitudes toward end-of-life care were similar among doctors in training and doctors who had been in practice, the ACP study revealed more about the roles that palliative care experience and religious involvement play in physicians’ views.

Of the ACP members who supported terminal sedation, nearly two-thirds of them (62 percent) did not support assisted suicide. Analysis revealed physicians were more likely to be for terminal sedation but against assisted suicide if they had either significant experience with dying patients or frequent religious service attendance.

Among ACP physicians who had cared for one to 10 terminally ill patients in the past year, 39 percent disagreed with the notion of assisted suicide. In contrast, among ACP physicians who had cared for 50 or more terminally ill patients in the past year, 68 percent disagreed with assisted suicide. “It was clear from our statistical analysis that those who had cared for a greater number of terminally patients in the preceding year were more opposed to assisted suicide and also more supportive of terminal sedation,” Kaldjian said. “There seemed to be both a greater willingness to be rigorous in end-of-life care but also less willingness to cross that line into actually intending death,” he added. Kaldjian said the reasons for this attitude are open for discussion because the statistical study was descriptive, not designed to establish cause and effect.

The ACP study also showed that the more frequently a doctor attended religious services, the more likely he or she was to disagree with assisted suicide, as shown by these disagreement rates: 30 percent for non-attendees, 33 percent for less-than-monthly attendees, 52 percent for monthly attendees and 76 percent for weekly attendees. “We found that the more frequently respondents attended religious services, there was a trend toward less support for assisted suicide but more support for terminal sedation,” Kaldjian said. “To my knowledge, this is the first study to show such a stepwise trend.”

The association with frequency of religious service attendance held true no matter what the religious affiliation of the physician. Kaldjian said the studies collectively suggest that physicians do not separate their religious beliefs from decision-making in end-of-life care. “We should not be surprised that physicians have religious beliefs and that, especially in some areas of medicine, these beliefs are operating in some way,” he said. “A physician should not be seen as any less of a professional because of deeply-held religious convictions.

“Medical ethics involve not just a patient’s autonomy but also a physician’s integrity,” he added. “On matters of such importance as end-of-life care, physicians’ integrity must be respected. Patients should not see themselves as mere consumers of health care but as partners in a decision-making process with physicians, who are not mere robots.”

The ACP-based study was funded in part by a dissertation fellowship to Kaldjian from the Graduate School at Yale University.