Facing a request for assisted death - views of Finnish physicians, a mixed method study.

BACKGROUND: Assisted death, including euthanasia and physician-assisted suicide (PAS), is under debate worldwide, and these practices are adopted in many Western countries. Physicians' attitudes toward assisted death vary across the globe, but little is known about physicians' actual reactions when facing a request for assisted death. There is a clear gap in evidence on how physicians act and respond to patients' requests for assisted death in countries where these actions are not legal. METHODS: A survey including statements concerning euthanasia and PAS and an open question about their actions when facing a request for assisted death was sent to all Finnish physicians. Quantitative data are presented as numbers and percentages. Statistical significance was tested by using the Pearson chi-square test, when appropriate. The qualitative analysis was performed by using an inductive content analysis approach, where categories emerge from the data. RESULTS: Altogether, 6889 physicians or medical students answered the survey, yielding a response rate of 26%. One-third of participants agreed or partly agreed that they could assist a patient in a suicide. The majority (69%) of the participants fully or partly agreed that euthanasia should only be accepted due to difficult physical symptoms, while 12% fully or partly agreed that life turning into a burden should be an acceptable reason for euthanasia. Of the participants, 16% had faced a request for euthanasia or PAS, and 3033 answers from 2565 respondents were achieved to the open questions concerning their actions regarding the request and ethical aspects of assisted death. In the qualitative analysis, six main categories, including 22 subcategories, were formed regarding the phenomenon of how physicians act when facing this request. The six main categories were as follows: providing an alternative to the request, enabling care and support, ignoring the request, giving a reasoned refusal, complying with the request, and seeing the request as a possibility. CONCLUSIONS: Finnish physicians' actions regarding the requests for assisted death, and attitudes toward euthanasia and PAS vary substantially. Open discussion, education, and recommendations concerning a request for assisted death and ethics around it are also highly needed in countries where euthanasia and PAS are not legal.

Ambivalence toward euthanasia and physician-assisted suicide has decreased among physicians in Finland.

BACKGROUND: Debates around euthanasia and physician-assisted suicide (PAS) are ongoing around the globe. Public support has been mounting in Western countries, while some decline has been observed in the USA and Eastern Europe. Physicians' support for euthanasia and PAS has been lower than that of the general public, but a trend toward higher acceptance among physicians has been seen in recent years. The aim of this study was to examine the current attitudes of Finnish physicians toward euthanasia and PAS and whether there have been changes in these attitudes over three decades. METHODS: A questionnaire survey was conducted with all Finnish physicians of working age in 2020 and the results were compared to previous studies conducted in 1993, 2003 and 2013. RESULTS: The proportions of physicians fully agreeing and fully disagreeing with the legalization of euthanasia increased from 1993 to 2020 (from 5 to 25%, p < 0.001, and from 30 to 34%, p < 0.001, respectively). The number of physicians, who expressed no opinion for or against euthanasia (cannot say) decreased from 19 to 5% (p < 0.001) during the same period. The proportion of physicians having no opinion (cannot say) of whether a physician should be punished for assisting in a suicide decreased from 20 to 10% (p < 0.001). CONCLUSIONS: This study shows that Finnish physicians' ambivalence toward euthanasia and PAS has decreased. The ongoing debate has probably forced physicians to form more solid opinions on these matters. Our study highlights that attitudes toward euthanasia and PAS are still divided within the medical profession.

Physicians' decreased tendency to choose palliative care for patients with advanced dementia between 1999 and 2015.

BACKGROUND: Physicians' decision-making for seriously ill patients with advanced dementia is of high importance, especially as the prevalence of dementia is rising rapidly, and includes many challenging ethical, medical and juridical aspects. We assessed the change in this decision-making over 16 years (from 1999 to 2015) and several background factors influencing physicians' decision. METHODS: A postal survey including a hypothetical patient-scenario representing a patient with an advanced dementia and a life-threatening gastrointestinal bleeding was sent to 1182 and 1258 Finnish physicians in 1999 and 2015, respectively. The target groups were general practitioners (GPs), surgeons, internists and oncologists. The respondents were asked to choose between several life-prolonging and palliative care approaches. The influence of physicians' background factors and attitudes on their decision were assessed. RESULTS: The response rate was 56%. A palliative care approach was chosen by 57 and 50% of the physicians in 1999 and 2015, respectively (p = 0.01). This change was statistically significant among GPs (50 vs 40%, p = 0.018) and oncologists (77 vs 56%, p = 0.011). GPs chose a palliative care approach less often than other responders in both years (50 vs. 63% in 1999 and 40 vs. 56% in 2015, p < 0.001). In logistic regression analysis, responding in 2015 and being a GP remained explanatory factors for a lower tendency to choose palliative care. The impact of family's benefit on the decision-making decreased, whereas the influence of the patient's benefit and ethical values as well as the patient's or physician's legal protection increased from 1999 to 2015. CONCLUSIONS: Physicians chose a palliative care approach for a patient with advanced dementia and life-threatening bleeding less often in 2015 than in 1999. Specialty, attitudes and other background factors influenced significantly physician decision-making. Education on the identification and palliative care of the patients with late-stage dementia are needed to make these decisions more consistent.

Does special education in palliative medicine make a difference in end-of-life decision-making?

BACKGROUND: Characteristics of the physician influence the essential decision-making in end-of-life care. However, the effect of special education in palliative medicine on different aspects of decision-making in end-of-life care remains unknown. The aim of this study was to explore the decision-making in end-of-life care among physicians with or without special competency in palliative medicine (cPM). METHODS: A questionnaire including an advanced lung cancer patient-scenario with multiple decision options in end-of-life care situation was sent to 1327 Finnish physicians. Decisions to withdraw or withhold ten life-prolonging interventions were asked on a scale from 1 (definitely would not) to 5 (definitely would) - first, without additional information and then after the family's request for aggressive treatment and the availability of an advance directive. Values from chronological original scenario, family's appeal and advance directive were clustered by trajectory analysis. RESULTS: We received 699 (53%) responses. The mean values of the ten answers in the original scenario were 4.1 in physicians with cPM, 3.4 in general practitioners, 3.4 in surgeons, 3.5 in internists and 3.8 in oncologists (p < 0.05 for physicians with cPM vs. oncologists and p < 0.001 for physicians with cPM vs. others). Younger age and not being an oncologist or not having cPM increased aggressive treatment decisions in multivariable logistic regression analysis. The less aggressive approach of physicians with cPM differed between therapies, being most striking concerning intravenous hydration, nasogastric tube and blood transfusions. The aggressive approach increased by the family's request (p < 0.001) and decreased by an advance directive (p < 0.001) in all physicians, regardless of special education in palliative medicine. CONCLUSION: Physicians with special education in palliative medicine make less aggressive decisions in end-of-life care. The impact of specialty on decision-making varies among treatment options. Education in end-of-life care decision-making should be mandatory for young physicians and those in specialty training.

Changes in attitudes towards hastened death among Finnish physicians over the past sixteen years.

BACKGROUND: The ethics of hastened death are complex. Studies on physicians' opinions about assisted dying (euthanasia or assisted suicide) exist, but changes in physicians' attitudes towards hastened death in clinical decision-making and the background factors explaining this remain unclear. The aim of this study was to explore the changes in these attitudes among Finnish physicians. METHODS: A questionnaire including hypothetical patient scenarios was sent to 1182 and 1258 Finnish physicians in 1999 and 2015, respectively. Two scenarios of patients with advanced cancer were presented: one requesting an increase in his morphine dose to a potentially lethal level and another suffering a cardiac arrest. Physicians' attitudes towards assisted death, life values and other background factors were queried as well. The response rate was 56%. RESULTS: The morphine dose was increased by 25% and 34% of the physicians in 1999 and 2015, respectively (p < 0.001). Oncologists approved the increase most infrequently without a significant change between the study years (15% vs. 17%, p = 0.689). Oncological specialty, faith in God, female gender and younger age were independent factors associated with the reluctance to increase the morphine dose. Euthanasia, but not assisted suicide, was considered less reprehensible in 2015 (p = 0.008). In both years, most physicians (84%) withheld cardiopulmonary resuscitation. CONCLUSION: Finnish physicians accepted the risk of hastening death more often in 2015 than in 1999. The physicians' specialty and many other background factors influenced this acceptance. They also regarded euthanasia as less reprehensible now than they did 16 years ago.

Palliative gastrointestinal surgical oncology-outcomes after palliative care consultation: retrospective observational study.

OBJECTIVES: Palliative surgery aims to relieve patients' symptoms and improve quality of life with surgical interventions. While a multidisciplinary approach has been found beneficial for critically ill patients, limited evidence supports this approach in palliative surgery. Here we sought to study whether palliative care consultations can improve outcomes among patients undergoing palliative surgery. METHODS: Consecutive patients undergoing palliative care at gastrosurgical wards in a tertiary Finnish university hospital during a 2-year study period were included. Outcomes of those undergoing surgery with or without palliative care consultation were compared. The main outcome measures were patients' functional status, postoperative morbidity and mortality. RESULTS: A total of 312 patients were included, of whom 173 underwent surgery, 77 endoscopic care and 62 were treated conservatively. Of the operated patients, 24 underwent multidisciplinary assessment while among the rest, the treatment decision was based on the surgeons' assessment. Multidisciplinary assessment was associated with a clinically significantly reduced morbidity (8.3% vs 23%, p=0.111), in-hospital mortality (8.3% vs 17%, p=0.051) and rate of hospital readmissions (8.3% vs 21%, p=0.052). There was no difference in median survival 49 (2-440) vs 45 (1-971) days (p=0.949). Of those undergoing conservative care, 44% could have undergone surgery. CONCLUSIONS: The aim of the palliative surgery is to relieve symptoms among patients with no hope of being cured. While the involvement of the palliative care consultation into the surgical decision-making is likely to reduce unnecessary operations, it is likely to be even more important in improving quality of end-of-life care.

End-of-life Decision-making Differs Between a Cancer and a Dementia Patient: Influences of the Physician's Background Factors.

BACKGROUND/AIM: Appropriate decision-making is essential for end-of-life (EOL) care without futile therapies. However, these decisions might vary in cases of cancer and other advanced diseases according to physicians' experience, education, and values. This study aimed to compare the decisions in EOL care of advanced cancer and dementia and the factors that influence them in medical students, general practitioners (GPs), and physicians with special competence in palliative medicine (cPM). PATIENTS AND METHODS: A questionnaire presenting patient scenarios concerning different decisions and ethical aspects of EOL care with additional questions on attitudes and background factors was delivered to 500 Finnish GPs, all Finnish physicians with cPM (n=82), and all graduating medical students (n=639) in 2015-2016. Altogether 601 responses were obtained (53%). RESULTS: Palliative care was chosen more often for a patient with advanced prostate cancer (83%) than for a patient with advanced dementia (41%) (both patients males, same age). A suspicion of iatrogenic bleeding in the prostate cancer patient decreased the willingness to choose palliative care, especially among the students. Patient benefit was regarded as an important background factor in decision making by all respondent groups, but physicians' legal protection was not considered as important among the physicians with cPM as it was among the other respondent groups. CONCLUSION: Finnish doctors and students were more likely to choose palliative care options for an advanced prostate cancer patient than for an advanced dementia patient. Decision-making was influenced by respondents' background factors and attitudes. Education on EOL care for different types of advanced and incurable diseases is highly needed.

Palliation of Dyspnea With Mouthpiece Ventilation in Patients With Chronic Obstructive Pulmonary Disease: A Pilot Feasibility Study.

Background: Mouthpiece ventilation (MPV) reduces hypoventilation, but its efficacy in relieving dyspnea in patients with acute chronic obstructive pulmonary disease exacerbation (AECOPD) is unclear. Objective: To assess the feasibility of MPV in relieving dyspnea among patients with AECOPD. Methods: In this prospective single-arm pilot study, the change in dyspnea on numeric rating scale (NRS) after using MPV and side effects of the treatment were studied in 18 patients with AECOPD. Results: The median decrease in dyspnea was 1.5 (95% confidence interval = 0.0-2.5, p = 0.006) on NRS after the intervention lasting a median of 16.9 minutes. Of the patients, 61% found MPV beneficial. The use of MPV did not increase the sense of anxiety or pain. Conclusions: MPV is feasible and may relieve dyspnea in patients with AECOPD, but the intervention needs further evaluation. clinicaltrials.gov study number: NCT03025425.

Specialist Palliative Care Consultation for Patients with Nonmalignant Pulmonary Diseases: A Retrospective Study.

Background: Few patients with chronic nonmalignant pulmonary diseases receive specialist palliative care consultation, despite their high symptom burden in end of life. Objectives: To study palliative care decision making, survival, and hospital resource usage in patients with nonmalignant pulmonary diseases with or without a specialist palliative care consultation. Methods: A retrospective chart review of all patients with a chronic nonmalignant pulmonary disease and a palliative care decision (palliative goal of therapy), who were treated in Tampere University Hospital, Finland, between January 1, 2018 and December 31, 2020. Results: A total of 107 patients were included in the study, 62 (58%) had chronic obstructive pulmonary disease (COPD), and 43 (40%) interstitial lung disease (ILD). Median survival after palliative care decision was shorter in patients with ILD than in patients with COPD (59 vs. 213 days, p = 0.004). Involvement of a palliative care specialist in the decision making was not associated with the survival. Patients with COPD who received palliative care consultation visited less often emergency room (73% vs. 100%, p = 0.019) and spent fewer days in the hospital (7 vs. 18 days, p = 0.007) during the last year of life. When a palliative care specialist attended the decision making, the presence and opinions of the patients were recorded more often, and the patients were more frequently referred to a palliative care pathway. Conclusions: Specialist palliative care consultation seems to enable better end-of-life care and supports shared decision making for patients with nonmalignant pulmonary diseases. Therefore, palliative care consultations should be utilized in nonmalignant pulmonary diseases preferably before the last days of life.

Has there been a change in the end-of-life decision-making over the past 16 years?

OBJECTIVES: Physicians' decision-making in end-of-life (EOL) care includes many medical, ethical and juridical aspects. We studied the changes of these decisions over time and factors influencing them. METHODS: A postal survey including two hypothetical patient scenarios was sent to 1258 Finnish physicians in 2015 and to 1182 in 1999. The attitudes, values and background factors of the physicians were also enquired. RESULTS: The response rate was 56%. The physicians' decisions to choose palliative approaches over active or intensive care increased from 1999 to 2015 when a terminally ill prostate cancer patient had probable iatrogenic gastrointestinal bleeding (53% vs 59%, p=0.014) and waited to meet his son (46% vs 60%, p<0.001) or a minister (53% vs 71%, p<0.001). Training in EOL care independently increased palliative approaches. Patient's benefit (96% vs 99%, p=0.001), ethical values (83% vs 93%, p<0.001) and patient's (68% vs 86%, p<0.001) or physician's (44% vs 63%, p<0.001) legal protection were considered more influential to the decisions in 2015, while the family's benefit was regarded as less influential to the decisions than it was in 1999 (37% vs 25%, p<0.001). Physicians were more willing to give a hospice voucher for an advanced breast cancer patient in 2015 (34% vs 58%, p<0.001). CONCLUSIONS: Our findings may reflect the transition to a stronger emphasis on patient-centred care and a stronger tendency to avoid futile therapies that have only short-term goals. The results highlight that education in all aspects of EOL care should be incorporated into the post-graduate training of medical specialties that take care of dying patients.

Does Decision-making in End-of-life Care Differ Between Graduating Medical Students and Experienced Physicians?

BACKGROUND/AIM: Appropriate decision-making in end-of-life (EOL) care is essential for both junior and senior physicians. The aim of this study was to compare the decision-making and attitudes of medical students with those of experienced general practitioners (GP) regarding EOL-care. MATERIALS AND METHODS: A questionnaire presenting three cancer patient scenarios concerning decisions and ethical aspects of EOL-care was offered to 500 Finnish GPs and 639 graduating medical students in 2015-2016. RESULTS: Responses were received from 222 (47%) GPs and 402 (63%) students. The GPs withdrew antibiotics (p<0.001) and nasogastric tubes (p=0.007) and withheld resuscitation (p<0.001), blood transfusions (p=0.002) and pleural drainage (p<0.001) more often than did the students. The students considered euthanasia and assisted suicide less reprehensible (p<0.001 in both) than did the GPs. CONCLUSION: Medical students were more unwilling to withhold and withdraw therapies in EOL-care than were the GPs, but the students considered euthanasia less reprehensible. Medical education should include aspects of decision-making in EOL-care.

Therapeutic Procedures for Malignant Ascites in a Palliative Care Outpatient Clinic.

BACKGROUND: The optimal treatment of malignant ascites (MA) and feasibility of the management with free drainage remain unclear. OBJECTIVE: To study the success of drainage, complications, and survival after paracentesis or insertion of an indwelling tunneled catheter (TC) for the MA performed on a day-case basis. DESIGN AND SETTING: We evaluated 118 paracenteses and 48 insertions of TCs performed in 104 patients with MA at the Palliative Care Outpatient Unit of Tampere University Hospital. RESULTS: Drainage of ascites fluid (median 3700 mL; range 300-13,200 mL) was successful in all cases. The complication rates were 7% and 25% for paracenteses and TCs, respectively. Most of the complications were minor. Repeated procedures were needed in 64% and 10% of the paracenteses and insertions of TCs, respectively, (p < 0.001). Median survival after the first procedure was 40 days (interquartile range, IQR: 17-115). Patients with pancreatic cancer had shorter median survival (19 days; IQR: 9-35) compared with other patients (47 days; IQR: 23-143) (age-adjusted HR 2.73; 95% CI: 1.65-4.52), whereas patients receiving chemotherapy had longer median survival (112 days; IQR: 43-205) compared with patients without chemotherapy (25 days; IQR: 14-52) (age-adjusted HR 2.48; 95% CI: 1.58-3.89). The volume of removed ascites fluid was not associated with survival. CONCLUSIONS: Free drainage of MA seems feasible in an outpatient clinic. Early insertion of TC should be considered to avoid repeated paracenteses. However, in patients with pancreatic cancer, paracentesis might be an accepted alternative due to their short life expectancy.