Influence of physicians' life stances on attitudes to end-of-life decisions and actual end-of-life decision-making in six countries.

AIM: To examine how physicians' life stances affect their attitudes to end-of-life decisions and their actual end-of-life decision-making. METHODS: Practising physicians from various specialties involved in the care of dying patients in Belgium, Denmark, The Netherlands, Sweden, Switzerland and Australia received structured questionnaires on end-of-life care, which included questions about their life stance. Response rates ranged from 53% in Australia to 68% in Denmark. General attitudes, intended behaviour with respect to two hypothetical patients, and actual behaviour were compared between all large life-stance groups in each country. RESULTS: Only small differences in life stance were found in all countries in general attitudes and intended and actual behaviour with regard to various end-of-life decisions. However, with regard to the administration of drugs explicitly intended to hasten the patient's death (PAD), physicians with specific religious affiliations had significantly less accepting attitudes, and less willingness to perform it, than non-religious physicians. They had also actually performed PAD less often. However, in most countries, both Catholics (up to 15.7% in The Netherlands) and Protestants (up to 20.4% in The Netherlands) reported ever having made such a decision. DISCUSSION: The results suggest that religious teachings influence to some extent end-of-life decision-making, but are certainly not blankly accepted by physicians, especially when dealing with real patients and circumstances. Physicians seem to embrace religious belief in a non-imperative way, allowing adaptation to particular situations.

Do family practitioners in Lithuania inform their patients about adverse effects of common medications?

OBJECTIVES: (1) To investigate the extent to which family physicians (GPs) in Lithuania inform their patients about possible side-effects when a common treatment is proposed. (2) To examine the relation between physicians' estimation of the severity and frequency of these side-effects and their willingness to inform patients. (3) To identify the reasons for informing or not informing the patients. METHODS: A questionnaire, presenting three hypothetical cases involving decisions about ordinary medical treatments and a series of general questions about information about side-effects, was distributed to 500 Lithuanian GPs. The response rate was 42%. RESULTS: The respondents differed considerably with regard to their willingness to inform patients about side-effects, but they informed their patients significantly more if the side effect was considered to be common and serious, than in cases when it was considered to be rare and trivial. The majority of the respondents informed their patients primarily to enable them to react appropriately to the side-effects in question. The major reason for not informing was that the side-effects were considered too rare to be relevant to the patient's decision-making. CONCLUSION: Information, given to patients about side-effects by Lithuanian GPs, is not in accordance with the principle of respect for patients' autonomy and requirements of Lithuanian legislation.

The secret art of managing healthcare expenses: investigating implicit rationing and autonomy in public healthcare systems.

Rationing healthcare is a difficult task, which includes preventing patients from accessing potentially beneficial treatments. Proponents of implicit rationing argue that politicians cannot resist pressure from strong patient groups for treatments and conclude that physicians should ration without informing patients or the public. The authors subdivide this specific programme of implicit rationing, or "hidden rationing", into local hidden rationing, unsophisticated global hidden rationing and sophisticated global hidden rationing. They evaluate the appropriateness of these methods of rationing from the perspectives of individual and political autonomy and conclude that local hidden rationing and unsophisticated global hidden rationing clearly violate patients' individual autonomy, that is, their right to participate in medical decision-making. While sophisticated global hidden rationing avoids this charge, the authors point out that it nonetheless violates the political autonomy of patients, that is, their right to engage in public affairs as citizens. A defence of any of the forms of hidden rationing is therefore considered to be incompatible with a defence of autonomy.

Treatment of severely diseased newborns: a survey of attitudes among Danish physicians.

In order to describe the attitudes towards treatment of severely diseased newborns a questionnaire presenting four fictive situations concerning infants with myelomeningocele, trisomy 13, Down's syndrome and epidermolysis bullosa lethalis was mailed to all physicians employed at obstetric or paediatric departments in Denmark. The questionnaire was designed in two versions, differing as regards the parents' situation and attitude towards treatment in two of the situations. Each version was sent to half of the sample. Of 954 questionnaires 664 (69.6%) were completed and returned. The parents' situation and attitude towards treatment played a role in forming the treatment choice to a significant proportion of the respondents, although the majority seemed to form their decisions independently of this factor. In the situations presenting the infants with myelomeningocele and Down's syndrome there was controversy concerning the level of active treatment, while only a minority would provide active treatment in the two other situations. In the case of epidermolysis bullosa lethalis most respondents would provide morphine in doses that could unintentionally hasten death, while few were in favour of legalizing active euthanasia.

[Decisions about life and death. An empirical study of the position of Danish physicians concerning end-of-life decisions]. / Beslutninger om liv og død. En empirisk undersøgelse af danske laegers holdninger til beslutninger ved livets afslutning.

In a postal questionnaire investigation of experiences and attitudes concerning end-of-life decisions among Danish physicians, most of the respondents reported having made decisions involving the hastening of a patient's death, and considered this acceptable. Such decisions were more frequent, and were considered ethically more acceptable, when made with the patient's informed consent than without. Of the respondents, two per cent had participated in assisted suicide, and five per cent had administered a lethal injection at the patient's request, practices considered ethically acceptable by 37 per cent and 34 per cent, respectively, of the respondents. The most frequently cited reasons for opposing such practices were double effect principle, the active killing/allowed-death distinction, and the sanctity of life; and the most frequently cited justifications were respect for the patient's autonomy, the avoidance of unnecessary suffering, and the patient's right to a death with dignity.

Treatment of extremely premature newborns: a survey of attitudes among Danish physicians.

In order to describe the attitudes towards the treatment of extremely preterm infants, a questionnaire presenting a series of fictitious situations concerning imminent extremely preterm labour and treatment of an infant born after 24 weeks gestation was mailed to all physicians employed at obstetrical or paediatric departments in Denmark. The questionnaire was designed in two versions, differing as regards the parents' situation and attitude towards treatment. Each version was sent to half of the sample. Of 954 questionnaires 664 (69.6%) were completed and returned. Most respondents advocated active treatment prior to and immediately upon delivery, but many would withhold more intensive treatments or withdraw treatments in case of severe complications. The parents' situation and attitude towards treatment played a role in forming the decision choice to a significant proportion of the respondents. In severe cases, many would provide morphine in doses that could unintentionally hasten death, while few were in favour of legalizing active euthanasia.

Limits of neonatal treatment: a survey of attitudes in the Danish population.

OBJECTIVES: To study attitudes in the Danish population towards treatment of severely handicapped and extremely preterm infants and to define areas of consensus and controversy. DESIGN: Mail-delivered questionnaire. SETTING: Denmark. Survey sample--A random sample of 1080 persons aged from 18 to 45 years. RESULTS: The overall response rate was 68%. There was strong consensus (more than 75% agreement) that life-prolonging treatment should be provided for an infant born after 24 weeks' gestation with respiratory distress and, for an infant with myelomeningocele, when the parents were in favour of treatment. Further, there was almost uniform agreement that not all infants should be treated no matter how serious the condition. Major controversies concerned the severity of a condition needed to justify omission of life-prolonging treatment, the role of parental attitude and the options in non-treatment cases. Forty-six per cent thought it ought to be legal to kill the infant in at least some of these cases. CONCLUSION: Although the study revealed wide divergences of opinion with regard to questions about limits of treatment and about end-of-life decisions it also showed that there was general acceptance both that life-prolonging treatment ought to be provided even in relatively severe cases if this was in accordance with parental wishes, and that life should not be saved at all costs.

Attitudes towards abortion among physicians working at obstetrical and paediatric departments in Denmark.

The purpose of this study was to describe the attitudes among physicians working in perinatal medicine towards abortion for social reasons or because of abnormal prenatal diagnostic results. A questionnaire was sent to all physicians registered as employed at obstetrical or paediatric departments in Danish hospitals with a neonatal function. Of 994 questionnaires, 687 (69 per cent) were completed and returned. There was strong consensus among all participants that abortion is acceptable until week 21 in the case of trisomy 13 and at least until week 19 in the case of cystic fibrosis. Furthermore, there was strong consensus that abortion in the first trimester is acceptable in the case of an unwanted pregnancy in a 16-year-old girl and in the case of Down syndrome. Major controversy was found in connection with abortion in the case of Turner syndrome until week 21, abortion in week 13 in the case of polycystic kidney disease, abortion in week 24 in the case of Down syndrome, and abortion for social reasons in week 21.

PIP: In Denmark, where abortion has been available on request until the 12th week of pregnancy since 1973, advances in prenatal diagnosis have produced controversy over sanctions beyond this limit in cases of severe fetal anomalies. This 1995 survey investigated attitudes toward abortion among physicians working in the obstetrics or pediatric departments of Danish hospitals with a neonatal function. 687 (69%) of the eligible registered physicians returned the postal questionnaire, in which they were asked their opinions on the acceptability of induced abortion in a series of case scenarios. Overall, the responses were indicative of a gradualist orientation, in which abortion is regarded as increasingly problematic as the fetus develops. There was strong consensus (above 75%) that abortion is acceptable in the case of teenage pregnancy and Down syndrome during the first trimester, in the case of cystic fibrosis at least through week 19, and for trisomy 13 until week 21. More controversial was abortion in the case of Turner syndrome before week 21, polycystic kidney disease at week 13, abortion for social indications at week 21, and abortion in the case of Down syndrome at week 24. In general, obstetricians were more liberal in their abortion-related attitudes than pediatricians. There was no correlation between abortion attitudes and physician age, gender, or political persuasion.

Changes in moral reasoning and the teaching of medical ethics.

Courses in medical ethics are becoming an integral part of many medical school curricula in Europe. At the medical school of the University of Copenhagen, a course on philosophy of medicine has been compulsory for all medical students since 1988. The effect of such courses on the ethical awareness and reasoning of medical students is not well understood and we have therefore found it of interest to study the effects of the Copenhagen course. For the study, we used a Danish version of the Defining Issues Test (DIT) which measures development in moral reasoning (Rest J R, 1979 Development in Judging Moral Issues. University of Minnesota Press, Minneapolis). The study was conducted as a pre- and post-test study without a control group, and the subjects were all medical students attending the course in the autumn of 1993. The results show that moral reasoning scores measured by the DIT increase significantly, and we argue that this increase can only be explained as an effect of the course.

Experimental pain in human temporal muscle induced by hypertonic saline, potassium and acidity.

The study was aimed at developing a reference model for experimental pain and tenderness in the human temporal muscle by the local injection of hypertonic saline, potassium chloride and acidic phosphate buffer, using isotonic saline as control. The design was randomized and double-blind. Twenty healthy subjects had 0.2 ml test solution injected into one temporal muscle and saline into the other. Following each injection, pain was rated on a 10-point ordinal scale and pressure-pain thresholds were measured every minute for 10 min by a pressure algometer. Hypertonic saline (n = 11) and potassium chloride (n = 12) induced significantly more pain than isotonic saline (ANOVA, p less than 0.0001). Compared to control injections, hypertonic saline and potassium chloride induced a significant reduction in pressure-pain threshold (ANOVA, p less than 0.0001 and p less than 0.05). Forty-eight percent of the injections led to the referral of pain most often to the jaws. A positive correlation between the relative occurrence of referred pain and pain intensity was observed (p less than 0.001) as was a negative correlation between the decrease in pressure-pain threshold and pain intensity (p less than 0.05).