Medical end-of-life practices in Swiss cultural regions: a death certificate study.

BACKGROUND: End-of-life decisions remain controversial. Switzerland, with three main languages shared with surrounding countries and legal suicide assistance, allows exploration of the effects of cultural differences on end-of-life practices within the same legal framework. METHODS: We conducted a death certificate study on a nationwide continuous random sample of Swiss residents. Using an internationally standardized tool, we sent 4998, 2965, and 1000 anonymous questionnaires to certifying physicians in the German-, French-, and Italian-speaking regions. RESULTS: The response rates were 63.5%, 51.9%, and 61.7% in the German-, French-, and Italian-speaking regions, respectively. Non-sudden, expected deaths were preceded by medical end-of-life decisions (MELDs) more frequently in the German- than in the French- or Italian-speaking region (82.3% vs. 75.0% and 74.0%, respectively), mainly due to forgoing life-prolonging treatment (70.0%, 59.8%, 57.4%). Prevalence of assisted suicide was similar in the German- and French-speaking regions (1.6%, 1.2%), with no cases reported in the Italian-speaking region. Patient involvement was smaller in the Italian- than in the French- and German-speaking regions (16.0%, 31.2%, 35.6%). Continuous deep sedation was more frequent in the Italian- than in the French- and German-speaking regions (34.4%, 26.9%, 24.5%), and was combined with MELDs in most cases. CONCLUSION: We found differences in MELD prevalence similar to those found between European countries. On an international level, MELDs are comparably frequent in all regions of Switzerland, in line with the greater role given to patient autonomy. Our findings show how cultural contexts and legislation can interact in shaping the prevalence of MELDs.

Solidarity and cost management: Swiss citizens' reasons for priorities regarding health insurance coverage.

CONTEXT: Approaches to priority-setting for scarce resources have shifted to public deliberation as trade-offs become more difficult. We report results of a qualitative analysis of public deliberation in Switzerland, a country with high health-care costs, an individual health insurance mandate and a strong tradition of direct democracy with frequent votes related to health care. METHODS: We adapted the Choosing Healthplans All Together (CHAT) tool, an exercise developed to transform complex health-care allocation decisions into easily understandable choices, for use in Switzerland. We conducted focus groups in twelve Swiss cities, recruiting from a range of socio-economic backgrounds in the three language regions. FINDINGS: Participants developed strategic arguments based on the importance of basic coverage for all, and of cost-benefit evaluation. They also expressed arguments relying on a principle of solidarity, in particular the importance of protection for vulnerable groups, and on the importance of medical care. They struggled with the place of personal responsibility in coverage decisions. In commenting on the exercise, participants found the degree of consensus despite differing opinions surprising and valuable. CONCLUSION: The Swiss population is particularly attentive to the costs of health care and means of reducing these costs. Swiss citizens are capable of making trade-offs and setting priorities for complex health issues.

Defining categories of actionability for secondary findings in next-generation sequencing.

Next-generation sequencing is increasingly used in clinical practice for the diagnosis of Mendelian diseases. Because of the high likelihood of secondary findings associated with this technique, the process of informing patients is beset with new challenges. One of them is regarding the type of secondary findings that ought to be disclosed to patients. The aim of this research is to propose a practical implementation of the notion of actionability, a common criteria justifying the disclosure of secondary findings but whose interpretation varies greatly among professionals. We distinguish three types of actionability corresponding to (1) well-established medical actions, (2) patient-initiated health-related actions and (3) life-plan decisions. We argue that actionability depends on the characteristics of the mutation or gene and on the values of patients. In discussing the return of secondary findings, it is important that the physician tries to get an impression of the specific situation and values of patients. Regarding variants of uncertain clinical significance in actionable genes, we found that different understandings of autonomy lead to different conclusions and that, for some of them, it may be legitimate to refrain from returning uncertain information.

Should gratitude be a requirement for access to live organ donation?

Gratitude is both expected and problematic in live organ donation. Are there grounds to require it, and to forbid access to live donor transplantation to a recipient who fails to signal that he feels any form of gratitude? Recipient gratitude is not currently required for organ donation, but it is expected and may be a moral requirement. Despite this, we argue that making it a condition for live organ transplantation would be unjustified. It would constitute a problematic and disproportionate punishment for perceived immoral behaviour on the part of the recipient. It would also bar the donor from positive aspects of organ donation that remain even in the absence of recipient gratitude. A potential recipient's lack of gratitude should be explored as a possible symptom of other morally problematic issues and integrated into the information provided to the potential donor. Recognition of the donor's gift and gratitude for it may also need to be expressed in part by others. This last aspect is relevant even in cases where the recipient feels and expresses gratitude.

Assisted Suicide in Switzerland: Clarifying Liberties and Claims.

Assisting suicide is legal in Switzerland if it is offered without selfish motive to a person with decision-making capacity. Although the 'Swiss model' for suicide assistance has been extensively described in the literature, the formally and informally protected liberties and claims of assistors and recipients of suicide assistance in Switzerland are incompletely captured in the literature. In this article, we describe the package of rights involved in the 'Swiss model' using the framework of Hohfeldian rights as modified by Wenar. After outlining this framework, we dissect the rights involved in suicide assistance in Switzerland, and compare it with the situation in England and Germany. Based on this approach, we conclude that in Switzerland, claim rights exist for those requesting suicide assistance, and for those who are considering providing such assistance, even though no entitlements exist toward suicide assistance. We then describe the implementation of the 'Swiss model' and difficulties arising within it. Clarifying these issues is important to understand the Swiss situation, to evaluate what features of it may or may not be worth correcting or emulating, and to understand how it can impact requests for suicide assistance in other countries due to 'suicide tourism'. It is also important to understand exactly what sets Switzerland apart from other countries with different legislations regarding suicide assistance.

Self-Reported Rationing Behavior Among US Physicians: A National Survey.

BACKGROUND: Rationing is a controversial topic among US physicians. Understanding their attitudes and behaviors around rationing may be essential to a more open and sensible professional discourse on this important but controversial topic. OBJECTIVE: To describe rationing behavior and associated factors among US physicians. DESIGN: Survey mailed to US physicians in 2012 to evaluate self-reported rationing behavior and variables related to this behavior. SETTING: US physicians across a full spectrum of practice settings. PARTICIPANTS: A total of 2541 respondents, representing 65.6 % of the original mailing list of 3872 US addresses. INTERVENTIONS: The study was a cross-sectional analysis of physician attitudes and self-reported behaviors, with neutral language representations of the behaviors as well as an embedded experiment to test the influence of the word "ration" on perceived responsibility. MAIN OUTCOME MEASURES: Overall percentage of respondents reporting rationing behavior in various contexts and assessment of attitudes toward rationing. KEY RESULTS: In total, 1348 respondents (53.1 %) reported having personally refrained within the past 6 months from using specific clinical services that would have provided the best patient care, because of health system cost. Prescription drugs (n = 1073 [48.3 %]) and magnetic resonance imaging (n = 922 [44.5 %]) were most frequently rationed. Surgical and procedural specialists were less likely to report rationing behavior (adjusted odds ratio [OR] [95 % CI], 0.8 [0.9-0.9] and 0.5 [0.4-0.6], respectively) compared to primary care. Compared with small or solo practices, those in medical school settings reported less rationing (adjusted OR [95 % CI], 0.4 [0.2-0.7]). Physicians who self-identified as very or somewhat liberal were significantly less likely to report rationing (adjusted OR [95 % CI], 0.7 [0.6-0.9]) than those self-reporting being very or somewhat conservative. A more positive opinion about rationing tended to align with greater odds of rationing. CONCLUSIONS: More than one-half of respondents engaged in behavior consistent with rationing. Practicing physicians in specific subgroups were more likely to report rationing behavior.

Fleshing out vulnerability.

In the literature on medical ethics, it is generally admitted that vulnerable persons or groups deserve special attention, care or protection. One can define vulnerable persons as those having a greater likelihood of being wronged - that is, of being denied adequate satisfaction of certain legitimate claims. The conjunction of these two points entails what we call the Special Protection Thesis. It asserts that persons with a greater likelihood of being denied adequate satisfaction of their legitimate claims deserve special attention, care or protection. Such a thesis remains vague, however, as long as we do not know what legitimate claims are. This article aims at dispelling this vagueness by exploring what claims we have in relation to health care - thus fleshing out a claim-based conception of vulnerability. We argue that the Special Protection Thesis must be enriched as follows: If individual or group X has a greater likelihood of being denied adequate satisfaction of some of their legitimate claims to (i) physical integrity, (ii) autonomy, (iii) freedom, (iv) social provision, (v) impartial quality of government, (vi) social bases of self-respect or (vii) communal belonging, then X deserves special attention, care or protection. With this improved understanding of vulnerability, vulnerability talk in healthcare ethics can escape vagueness and serve as an adequate basis for practice.

Telling the truth: medical students' progress with an ethical skill.

BACKGROUND: Truth-telling is a complex task requiring multiple skills in communication, understanding, and empathy. Its application in the context of breaking bad news (BBN) is distressing and problematic if conducted with insufficient skills. PURPOSE: We investigated the long-term influence of a simulated patient-based teaching intervention integrating the learning of communication skills within an ethical reflection on students' ethical attitudes towards truth-telling, perceived competence and comfort in BBN. METHODS: We followed two cohorts of medical students from the preclinical third year to their clinical rotations (fifth year). We analysed their ethical attitudes and level of comfort and competence in BBN before, after the intervention, and during clinical rotations. RESULTS: Students' ethical attitudes towards truth-telling remained stable. Students feeling uncomfortable or incompetent improved their level of perceived comfort or competence after the intervention, but those feeling comfortable or competent became more aware of the difficulty of the situation, and consequently decreased their level of comfort and competence. CONCLUSIONS: Confronting students with a realistic situation and integrating the practice of communication skills within an ethical reflection may be effective in maintaining ethical attitudes towards truth-telling, in developing new skills and increasing awareness about the difficulty and challenges of a BBN situation.

Including patients in resuscitation decisions in Switzerland: from doing more to doing better.

BACKGROUND: Decisions regarding Cardio-Pulmonary Resuscitation (CPR) and Do Not Attempt Resuscitation (DNAR) orders remain demanding, as does including patients in the process. OBJECTIVES: To explore physicians' justification for CPR/DNAR orders and decisions regarding patient inclusion, as well as their reports of how they initiated discussions with patients. METHODS: We administered a face-to-face survey to residents in charge of 206 patients including DNAR and CPR orders, with or without patient inclusion. RESULTS: Justifications were provided for 59% of DNAR orders and included severe comorbidity, patients and families' resuscitation preferences, patients' age, or poor prognosis or quality of life. Reasons to include patients in CPR/DNAR decisions were provided in 96% and 84% of cases, and were based on respect for autonomy, clinical assessment of the situation as not too severe, and the view that such inclusion was required. Reasons for not including patients were offered in 84% of cases for CPR and in 70% for DNAR. They included absent decision-making capacity, a clinical situation viewed as good (CPR) or offering little hope of recovery (DNAR), barriers to communication, or concern that discussions could be emotionally difficult or superfluous. Decisions made earlier in the patient's management were infrequently viewed as requiring revision. Residents reported a variety of introductions to discussions with patients. CONCLUSIONS: These results provide better understanding of reasons for CPR/DNAR decisions, reasons for patient inclusion or lack thereof, and ways in which such inclusion is initiated. They also point to potential side-effects of implementing CPR/DNAR recommendations without in-depth and practical training. This should be part of a regular audit and follow-up process for such recommendations.

Why physicians ought to lie for their patients.

Sometimes physicians lie to third-party payers in order to grant their patients treatment they would otherwise not receive. This strategy, commonly known as gaming the system, is generally condemned for three reasons. First, it may hurt the patient for the sake of whom gaming was intended. Second, it may hurt other patients. Third, it offends contractual and distributive justice. Hence, gaming is considered to be immoral behavior. This article is an attempt to show that, on the contrary, gaming may sometimes be a physician's duty. Under specific circumstances, gaming may be necessary from the viewpoint of the internal morality of medicine. Moreover, the objections against gaming are examples of what we call the idealistic fallacy, that is, the fallacy of passing judgments in a nonideal world according to ideal standards. Hence, the objections are inconclusive. Gaming is sometimes justified, and may even be required in the name of beneficence.

'Do not attempt resuscitation' and 'cardiopulmonary resuscitation' in an inpatient setting: factors influencing physicians' decisions in Switzerland.

OBJECTIVE: To determine the prevalence of cardiopulmonary resuscitation (CPR) and do-not-attempt-resuscitation (DNAR) orders, to define factors associated with CPR/DNAR orders and to explore how physicians make and document these decisions. METHODS: We prospectively reviewed CPR/DNAR forms of 1,446 patients admitted to the General Internal Medicine Department of the Geneva University Hospitals, a tertiary-care teaching hospital in Switzerland. We additionally administered a face-to-face survey to residents in charge of 206 patients including DNAR and CPR orders, with or without patient inclusion. RESULTS: 21.2% of the patients had a DNAR order, 61.7% a CPR order and 17.1% had neither. The two main factors associated with DNAR orders were a worse prognosis and/or a worse quality of life. Others factors were an older age, cancer and psychiatric diagnoses, and the absence of decision-making capacity. Residents gave four major justifications for DNAR orders: important comorbid conditions (34%), the patients' or their family's resuscitation preferences (18%), the patients' age (14.2%), and the absence of decision-making capacity (8%). Residents who wrote DNAR orders were more experienced. In many of the DNAR or CPR forms (19.8 and 16%, respectively), the order was written using a variety of formulations. For 24% of the residents, the distinction between the resuscitation order and the care objective was not clear. 38% of the residents found the resuscitation form useful. CONCLUSION: Patients' prognosis and quality of life were the two main independent factors associated with CPR/DNAR orders. However, in the majority of cases, residents evaluated prognosis only intuitively, and quality of life without involving the patients. The distinction between CPR/DNAR orders and the care objectives was not always clear. Specific training regarding CPR/DNAR orders is necessary to improve the CPR/DNAR decision process used by physicians.

Clinical indication as an ethical appraisal: the example of imaging before middle ear surgery.

PURPOSE OF THE STUDY: Asking whether imaging is indicated before middle ear surgery requires us to examine the question of indication more generally. PROCEDURES: Clinical indication integrates different levels, which are distinguished in this paper. As deciding whether or not an intervention is indicated requires different approaches on each of these levels, these approaches are also explored. RESULTS: Even when sufficient data are available to determine whether an intervention brings some benefit, knowing whether or not this intervention is indicated still requires us to answer 3 additional questions: (1) Is the intervention sufficiently beneficial to be clinically relevant? (2) Is the intervention 'reasonable' in terms of its opportunity costs? (3) How are we to decide which interventions 'make the cut', and which do not? Although we may all have an informed opinion on this topic, the question of the thresholds we ought to apply to very marginal benefits is one where the best answer can only be the one we have all agreed on. This requires a guideline integrating elements of procedural fairness, developed in conditions of protection from the risks of conflicts of interests. CONCLUSION: Although some of these questions integrate considerations of costs, not all do. However, all integrate value judgements, making clinical indication in part a question of ethical appraisal.