Lindy Willmott

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

Objective Futile treatment, which by definition cannot benefit a patient, is undesirable. This research investigated why doctors believe that treatment that they consider to be futile is sometimes provided at the end of a patients life. Design Semistructured in-depth interviews. Setting Three large tertiary public hospitals in Brisbane, Australia. Participants 96 doctors from emergency, intensive care, palliative care, oncology, renal medicine, internal medicine, respiratory medicine, surgery, cardiology, geriatric medicine and medical administration departments. Participants were recruited using purposive maximum variation sampling. Results Doctors attributed the provision of futile treatment to a wide range of inter-related factors. One was the characteristics of treating doctors, including their orientation towards curative treatment, discomfort or inexperience with death and dying, concerns about legal risk and poor communication skills. Second, the attributes of the patient and family, including their requests or demands for further treatment, prognostic uncertainty and lack of information about patient wishes. Third, there were hospital factors including a high degree of specialisation, the availability of routine tests and interventions, and organisational barriers to diverting a patient from a curative to a palliative pathway. Doctors nominated family or patient request and doctors being locked into a curative role as the main reasons for futile care. Conclusions Doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the end of life, educating the community about the limits of medicine and the need to plan for death and dying, and structural reform at the hospital level.

Palliative care and other physicians’ knowledge, attitudes and practice relating to the law on withholding/withdrawing life-sustaining treatment: Survey results

Background: To effectively care for people who are terminally ill, including those without decision-making capacity, palliative care physicians must know and understand the legal standing of Advance Care Planning in their jurisdiction of practice. This includes the use of advance directives/living wills and substitute decision-makers who can legally consent to or refuse treatment if there is no valid advance directive. Aim: This study aimed to investigate the knowledge, attitudes and practices of medical specialists most often involved in end-of-life care in relation to the law on withholding/withdrawing life-sustaining treatment from adults without decision-making capacity. Design/participants: A pre-piloted survey was posted to specialists in palliative, emergency, geriatric, renal and respiratory medicine; intensive care; and medical oncology in three Australian States. Surveys were analysed using SPSS 20 and SAS 9.3. Results: The overall response rate was 32% (867/2702) – 52% from palliative care specialists. Palliative care specialists and geriatricians had significantly more positive attitudes towards the law ( χ 42 2 = 94 . 352 ; p < 0.001) and higher levels of knowledge about the withholding/withdrawing life-sustaining treatment law ( χ 7 2 = 30 . 033 ; p < 0.001) than did the other specialists, while still having critical gaps in their knowledge. Conclusion: A high level of knowledge of the law is essential to ensure that patients’ wishes and decisions, expressed through Advance Care Planning, are respected to the maximum extent possible within the law, thereby according with the principles and philosophy of palliative care. It is also essential to protect health professionals from legal action resulting from unauthorised provision or cessation of treatment.

Palliative care, double effect and the law in Australia

Care and decision‐making at the end of life that promotes comfort and dignity is widely endorsed by public policy and the law. In ethical analysis of palliative care interventions that are argued potentially to hasten death, these may be deemed to be ethically permissible by the application of the doctrine of double effect, if the doctors intention is to relieve pain and not cause death. In part because of the significance of ethics in the development of law in the medical sphere, this doctrine is also likely to be recognized as part of Australias common law, although hitherto there have been no cases concerning palliative care brought before a court in Australia to test this. Three Australian States have, nonetheless, created legislative defences that are different from the common law with the intent of clarifying the law, promoting palliative care, and distinguishing it from euthanasia. However, these defences have the potential to provide less protection for doctors administering palliative care. In addition to requiring a doctor to have an appropriate intent, the defences insist on adherence to particular medical practice standards and perhaps require patient consent. Doctors providing end‐of‐life care in these States need to be aware of these legislative changes. Acting in accordance with the common law doctrine of double effect may not provide legal protection. Similar changes are likely to occur in other States and Territories as there is a trend towards enacting legislative defences that deal with the provision of palliative care.

Withholding and withdrawing life-sustaining treatment in a patient's best interests: Australian judicial deliberations

Intractable disputes about withholding and withdrawing life‐sustaining treatment from adults who lack capacity are rare but challenging. Judicial resolution may be needed in some of these cases. A central concept for judicial (and clinical) decision making in this area is a patients “best interests”. Yet what this term means is contested. There is an emerging Supreme Court jurisprudence that sheds light on when life‐sustaining treatment will, or will not, be judged to be in a patients best interests. Treatment that is either futile or overly burdensome is not in a patients best interests. Although courts will consider patient and family wishes, they have generally deferred to the views of medical practitioners about treatment decisions.

What does “futility” mean? An empirical study of doctors’ perceptions

Objective: To investigate how doctors define and use the terms “futility” and “futile treatment” in end‐of‐life care.

Two steps forward, one step back: advance care planning, Australian regulatory frameworks and the Australian Medical Association

The Australian Medical Association has recently adopted a policy position concerning advance care planning, which is generally supportive of extending patient self‐determination beyond the loss of decision‐making capacity. It calls for uniform national legislation for legally enforceable advance health directives (AHD), and statutory protection for practitioners who comply with valid AHD, or who do not comply on several grounds. Analysis of the grounds for non‐compliance indicate that they undermine patient autonomy, and aspects of the policy are inconsistent with current common law and statutory regimes that allow an adult to complete a legally binding AHD. The policy therefore threatens the patient self‐determination, which it endorses, and places doctors who participate in advance care planning at legal risk.

Autonomy versus futility? Barriers to good clinical practice in end-of-life care: A Queensland case

Findings from a Queensland coronial inquest highlight the complex clinical, ethical and legal issues that arise in end‐of‐life care when clinicians and family members disagree about a diagnosis of clinical futility. The tension between the law and best medical practice is highlighted in this case, as doctors are compelled to seek family consent to not commence a futile intervention. Good communication between doctors and families, as well as community and professional education, is essential to resolve tensions that can arise when there is disagreement about treatment at the end of life.

Doctors’ perspectives on law and life-sustaining treatment: Survey design and recruitment strategies for a challenging cohort

Background: Palliative medicine and other specialists play significant legal roles in decisions to withhold and withdraw life-sustaining treatment at the end of life. Yet little is known about their knowledge of or attitudes to the law, and the role they think it should play in medical practice. Consideration of doctors’ views is critical to optimizing patient outcomes at the end of life. However, doctors are difficult to engage as participants in empirical research, presenting challenges for researchers seeking to understand doctors’ experiences and perspectives. Aims: To determine how to engage doctors involved in end-of-life care in empirical research about knowledge of the law and the role it plays in medical practice at the end of life. Methods: Postal survey of all specialists in palliative medicine, emergency medicine, geriatric medicine, intensive care, medical oncology, renal medicine, and respiratory medicine in three Australian states: New South Wales, Victoria, and Queensland. The survey was sent in hard copy with two reminders and a follow up reminder letter was also sent to the directors of hospital emergency departments. Awareness was further promoted through engagement with the relevant medical colleges and publications in professional journals; various incentives to respond were also used. The key measure is the response rate of doctors to the survey. Results: Thirty-two percent of doctors in the main study completed their survey with response rate by specialty ranging from 52% (palliative care) to 24% (medical oncology). This overall response rate was twice that of the reweighted pilot study (16%). Conclusions: Doctors remain a difficult cohort to engage in survey research but strategic recruitment efforts can be effective in increasing response rate. Collaboration with doctors and their professional bodies in both the development of the survey instrument and recruitment of participants is essential.

Rethinking Restrictive Practices: A Comparative Analysis

This paper undertakes the first comparative analysis of restrictive practices legislation in Australia. This legislation, which regulates practices used to manage ‘challenging behaviours’ of people with intellectual disability or cognitive impairment, currently exists in four Australian jurisdictions. The paper demonstrates the gaps in coverage of this legislation and the wide variation of law nationally. We argue that legislation governing restrictive practices is needed, it should regulate the provision of all restrictive practices (not just some) and that there should be a national consistent approach.

Incidence, duration and cost of futile treatment in end-of-life hospital admissions to three Australian public-sector tertiary hospitals: a retrospective multicentre cohort study

Objectives To estimate the incidence, duration and cost of futile treatment for end-of-life hospital admissions. Design Retrospective multicentre cohort study involving a clinical audit of hospital admissions. Setting Three Australian public-sector tertiary hospitals. Participants Adult patients who died while admitted to one of the study hospitals over a 6-month period in 2012. Main outcome measures Incidences of futile treatment among end-of-life admissions; length of stay in both ward and intensive care settings for the duration that patients received futile treatments; health system costs associated with futile treatments; monetary valuation of bed days associated with futile treatment. Results The incidence rate of futile treatment in end-of-life admissions was 12.1% across the three study hospitals (range 6.0%–19.6%). For admissions involving futile treatment, the mean length of stay following the onset of futile treatment was 15 days, with 5.25 of these days in the intensive care unit. The cost associated with futile bed days was estimated to be