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BMC Palliative Care
Published in: BMC Palliative Care 1/2017

Open Access 01-12-2017 | Research article

Comparing doctors’ legal compliance across three Australian states for decisions whether to withhold or withdraw life-sustaining medical treatment: does different law lead to different decisions?

Authors: Ben P. White, Lindy Willmott, Colleen Cartwright, Malcolm Parker, Gail Williams, Juliet Davis

Published in: BMC Palliative Care | Issue 1/2017

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Abstract

Background

Law purports to regulate end-of-life care but its role in decision-making by doctors is not clear. This paper, which is part of a three-year study into the role of law in medical practice at the end of life, investigates whether law affects doctors’ decision-making. In particular, it considers whether the fact that the law differs across Australia’s three largest states – New South Wales (NSW), Victoria and Queensland – leads to doctors making different decisions about withholding and withdrawing life-sustaining treatment from adults who lack capacity.

Methods

A cross-sectional postal survey of the seven specialties most likely to be involved in end-of-life care in the acute setting was conducted between 18 July 2012 and 31 January 2013. The sample comprised all medical specialists in emergency medicine, geriatric medicine, intensive care, medical oncology, palliative medicine, renal medicine and respiratory medicine on the AMPCo Direct database in those three Australian states. The survey measured medical specialists’ level of legal compliance, and reasons for their decisions, concerning the withholding or withdrawal of life-sustaining treatment. Multivariable logistic regression was used to examine predictors of legal compliance. Linear regression was used to examine associations between the decision about life-sustaining treatment and the relevance of factors involved in making these decisions, as well as state differences in these associations.

Results

Response rate was 32% (867/2702). A majority of respondents in each state said that they would provide treatment in a hypothetical scenario, despite an advance directive refusing it: 72% in NSW and Queensland; 63% in Victoria. After applying differences in state law, 72% of Queensland doctors answered in accordance with local law, compared with 37% in Victoria and 28% in NSW (p < 0.001). Doctors reported broadly the same decision-making approach despite differences in local law.

Conclusions

Law appears to play a limited role in medical decision-making at the end of life with doctors prioritising patient-related clinical and ethical considerations. Different legal frameworks in the three states examined did not lead to different decisions about providing treatment. More education is needed about law and its role in this area, particularly where law is inconsistent with traditional practice.
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Literature
1.
Foster C, Miola J. Who's in charge? The relationship between medical law, medical ethics, and medical morality? Med Law Rev. 2015;23:505–30.CrossRefPubMed
2.
Herring J. Medical law and ethics. 5th ed. Oxford: Oxford University Press; 2014. Chapter 4, Consent to treatment; p. 148-220. Chapter 9, Dying and death; p. 475-562.
3.
White B, McDonald F, Willmott L, editors. Health law in Australia. 2nd ed. Sydney: Thomson Reuters; 2014. Chapter 7, Adults who lack capacity: substitute decision-making; p. 193-253. Chapter 14, Withholding and withdrawing life-sustaining medical treatment; p. 543-91.
4.
5.
Lautrette A, Peigne V, Watts J, Souweine B, Azoulay E. Surrogate decision makers for incompetent ICU patients: a European perspective. Curr Opin Crit Care. 2008;14(6):714–9.CrossRefPubMed
6.
Venkat A, Becker J. The effect of statutory limitations on the authority of substitute decision makers on the care of patients in the intensive care unit: case examples and review of state laws affecting withdrawing or withholding life-sustaining treatment. J Intensive Care Med. 2014;29(2):71–80.CrossRefPubMed
7.
Wong RE, Weiland TJ, Jelinek GA. Emergency clinicians’ attitudes and decisions in patient scenarios involving advance directives. Emerg Med J. 2012;29:720–4.CrossRefPubMed
8.
Burkle CM, Mueller PS, Swetz KM, et al. Physician perspectives and compliance with patient advance directives: the role external factors play on physician decision making. BMC Med Ethics. 2012;13:31.CrossRefPubMedPubMedCentral
9.
Corke C, Milnes S, Orford N, et al. The influence of medical enduring power of attorney and advance directives on decision-making by Australian intensive care doctors. Crit Care Resusc. 2009;11:122–8.PubMed
10.
Hardin SB, Yusufaly YA. Difficult end-of-life treatment decisions: do other factors trump advance directives? Arch Intern Med. 2004;164:1531–3.CrossRefPubMed
11.
White B, Willmott L, Cartwright C, et al. Doctors’ knowledge of the law on withholding and withdrawing life-sustaining medical treatment. Med J Aust. 2014;201:229–32.CrossRefPubMed
12.
White B, Willmott L, Williams G, et al. The role of law in decisions to withhold and withdraw life-sustaining treatment from adults who lack capacity: a cross-sectional study. J Med Ethics. 2016;43:327–33.CrossRefPubMed
13.
Cartwright C, White B, Willmott L, et al. Palliative care and other physicians’ knowledge, attitudes and practice relating to the law on withholding/withdrawing life-sustaining treatment: survey results. Palliat Med. 2016;30(2):171–9.CrossRefPubMed
14.
ES DM, Dudzinski DM, Doyle KC, et al. Who decides when a patient Can’t? Statutes on alternate decision makers. N Engl J Med. 2017;376(15):1478–82.CrossRef
15.
16.
White B, Willmott L, Trowse P, et al. The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: part 1 (New South Wales). J Law Med. 2011;18:498–522.PubMed
17.
Willmott L, White B, Parker M, et al. The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: part 2 (Queensland). J Law Med. 2011;18:523–44.PubMed
18.
Willmott L, White B, Parker M, et al. The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: part 3 (Victoria). J Law Med. 2011;18:773–97.PubMed
19.
Scott A, Jeon SH, Joyce C, et al. A randomised trial and economic evaluation of the effect of response mode on response rate, response bias, and item non-response in a survey of doctors. BMC Med Res Methodol. 2011;11(1):126.CrossRefPubMedPubMedCentral
20.
White B, Willmott L, Parker M, et al. Should law have a role in end-of-life care? Intern Med J. 2012;42(9):966–8.CrossRefPubMed
21.
White B, Willmott L, Parker M, et al. What do emergency physicians think of law? Emerg Med Australas. 2012;24(4):355–6.CrossRefPubMed
22.
Willmott L, White B, Cartwright C, et al. Doctors’ perspectives on law and life-sustaining treatment: survey design and recruitment strategies for a challenging cohort. Prog Palliat Care. 2016;24:213–20.CrossRef
23.
Senate Community Affairs References Committee. Palliative care in Australia. Canberra: Commonwealth of Australia; 2012.
24.
White B, Tilse C, Wilson J, et al. Prevalence and predictors of advance directives in Australia. Intern Med J. 2014;44:975–80.CrossRefPubMed
25.
Hunter and New England Area Health Service v A (2009) 74 NSWLR 88: [40].
26.
Parker M, Willmott L, White B, et al. Medical education and law: withholding/withdrawing treatment from adults without capacity. Intern Med J. 2015;45:634–40.CrossRefPubMed
27.
Van Geest JB, Johnson TP, Welch VL. Methodologies for improving response rates in surveys of physicians: a systematic review. Eval Health Prof. 2007;30:303–21.CrossRef
28.
Cook JV, Dickinson HO, Eccles MP. Response rates in postal surveys of healthcare professionals between 1996 and 2005: an observational study. BMC Health Serv Res. 2009;9:160.CrossRefPubMedPubMedCentral
29.
Darvall L, McMahon M, Piterman L. Medico-legal knowledge of general practitioners: disjunctions, errors and uncertainties. J Law Med. 2001;9:167–84.PubMed
30.
31.
Carver AC, Vickrey BG, Bernat JL, et al. End-of-life care: a survey of US neurologists’ attitudes, behavior, and knowledge. Neurology. 1999;53:284–93.CrossRefPubMed
32.
Perkins HS, Bauer RL, Hazuda HP, et al. Impact of legal liability, family wishes, and other “external factors” on physicians’ life-support decisions. Am J Med. 1990;89:185–94.CrossRefPubMed
33.
McCrary SV, Swanson JW, Coulehan J, et al. Physicians’ legal defensiveness in end-of-life treatment decisions: comparing attitudes and knowledge in states with different laws. J Clin Ethics. 2006;17:15–26.PubMed
34.
SV MC, Swanson JW, Perkins HS, et al. Treatment decisions for terminally ill patients: physicians’ legal defensiveness and knowledge of medical law. Law Med Health Care. 1992;20:364–76.
35.
McCrary SV, Swanson JW. Physicians’ legal defensiveness and knowledge of medical law: comparing Denmark and the USA. Scand J Public Health. 1999;27:18–21.CrossRefPubMed
36.
Schildmann J, Doyal L, Cushing A, et al. Decisions at the end of life: an empirical study on the involvement, legal understanding and ethical views of preregistration house officers. J Med Ethics. 2006;32:567–70.CrossRefPubMedPubMedCentral
37.
Stark Toller CA, Budge MM. Compliance with and understanding of advance directives among trainee doctors in the United Kingdom. J Palliat Care. 2006;22:141–6.
38.
Fagerlin A, Schneider CE. Enough: the failure of the living will. Hastings Cent Rep. 2004;34(2):30–42.CrossRefPubMed
Metadata
Title
Comparing doctors’ legal compliance across three Australian states for decisions whether to withhold or withdraw life-sustaining medical treatment: does different law lead to different decisions?
Authors
Ben P. White
Lindy Willmott
Colleen Cartwright
Malcolm Parker
Gail Williams
Juliet Davis
Publication date
01-12-2017
Publisher
BioMed Central
Published in
BMC Palliative Care / Issue 1/2017
Electronic ISSN: 1472-684X
DOI
https://doi.org/10.1186/s12904-017-0249-1

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