Background
Methods
Participants
Special competency in palliative medicine
Questionnaire
Case scenario
Statistical analysis
Results
Responders
Competency in PM | Surgeons | Internists | GPs | Oncologists | Total | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Number (% of total) | 67 | (10) | 142 | (20) | 153 | (22) | 245 | (35) | 92 | (13) | 699 | (100) |
Response rate, % | 82 | 47 | 51 | 49 | 63 | 53 | ||||||
Female, n (%) | 57 | (85) | 47 | (33) | 81 | (53) | 173 | (71) | 73 | (79) | 431 | (62) |
Median age (IQR) | 55 | (49–58) | 52 | (44–59) | 53 | (46–59) | 49 | (38–57) | 49 | (41–56) | 52 | (43–58) |
Age distribution, n (%) | ||||||||||||
< 35 | 0 | (0) | 4 | (3) | 4 | (3) | 42 | (17) | 2 | (2) | 52 | (7) |
35–49 | 20 | (30) | 52 | (37) | 51 | (33) | 84 | (34) | 46 | (50) | 253 | (36) |
> 49 | 47 | (70) | 86 | (61) | 98 | (64) | 119 | (49) | 44 | (48) | 394 | (56) |
Years from graduation, median (IQR)a | 27 | (21–32) | 26 | (17–34) | 26 | (20–32) | 21 | (9–31) | 22 | (14–29) | 25 | (15–32) |
Overall willingness to withhold or withdraw therapies
Decisions concerning individual treatments
Treatment | Scenario | Competency in PM | Surgeons | Internist | GPs | Oncologists | P-valuea | |||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Antibiotic | Original scenario | 41 | (65) | 72 | (51) | 78 | (51) | 128 | (53) | 45 | (54) | 0.399 |
Family’s appeal | 33 | (50) | 55 | (39) | 55 | (36) | 89 | (37)* | 34 | (37) | 0.353 | |
Advance directive | 58 | (87) | 116 | (83) | 122 | (82) | 204 | (84) | 82 | (89) | 0.641 | |
Mechanical ventilation | Original scenario | 63 | (96) | 119 | (85)* | 135 | (89) | 195 | (81)* | 83 | (91) | 0.008 |
Family’s appeal | 59 | (92) | 113 | (80)* | 126 | (83) | 175 | (72)* | 76 | (84) | 0.002 | |
Advance directive | 67 | (100) | 130 | (92)* | 147 | (98) | 228 | (94)* | 90 | (99) | 0.011 | |
Intravenous hydration | Original scenario | 43 | (65) | 31 | (22)** | 39 | (26)** | 85 | (35)** | 42 | (46)* | < 0.001 |
Family’s appeal | 26 | (40) | 21 | (15)** | 19 | (13)** | 58 | (24)* | 34 | (37) | < 0.001 | |
Advance directive | 58 | (88) | 64 | (46)** | 84 | (56)** | 162 | (67)* | 75 | (82) | < 0.001 | |
Nasogastric tube | Original scenario | 62 | (95) | 85 | (60)** | 98 | (65)** | 161 | (67)** | 63 | (69)** | < 0.001 |
Family’s appeal | 60 | (92) | 76 | (54)** | 87 | (58)** | 126 | (53)** | 64 | (70)* | < 0.001 | |
Advance directive | 64 | (97) | 105 | (75)** | 126 | (84)* | 203 | (84)* | 82 | (89) | 0.001 | |
Thrombos prophylaxis | Original scenario | 55 | (85) | 108 | (76) | 105 | (69)* | 151 | (62)* | 73 | (80) | < 0.001 |
Family’s appeal | 52 | (80) | 104 | (74) | 95 | (64)* | 128 | (53)** | 67 | (73) | < 0.001 | |
Advance directive | 63 | (96) | 121 | (88) | 127 | (85)* | 199 | (82)* | 86 | (94) | 0.013 | |
Supplementary oxygen | Original scenario | 11 | (16) | 16 | (11) | 23 | (15) | 14 | (6)* | 11 | (12) | 0.019 |
Family’s appeal | 12 | (18) | 14 | (10) | 13 | (9)* | 12 | (5) | 6 | (7)* | 0.011 | |
Advance directive | 20 | (30) | 40 | (28) | 46 | (31) | 51 | (21) | 27 | (29) | 0.189 |
Treatment | Scenario | Competency in PM | Surgeons | Internists | GPs | Oncologists | P-valuea | |||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Blood transfusion | Original scenario | 60 | (91) | 98 | (70)* | 108 | (72)* | 185 | (76)* | 72 | (78)* | 0.011 |
Family’s appeal | 55 | (85) | 90 | (64)* | 85 | (56)** | 153 | (64)* | 67 | (76) | < 0.001 | |
Advance directive | 66 | (99) | 132 | (94) | 136 | (91) | 227 | (94) | 90 | (98) | 0.134 | |
Pleural drainage | Original scenario | 43 | (65) | 59 | (42)* | 85 | (56) | 99 | (41)** | 58 | (64) | < 0.001 |
Family’s appeal | 41 | (63) | 57 | (40)* | 73 | (49) | 89 | (37)** | 51 | (56) | < 0.001 | |
Advance directive | 53 | (79) | 103 | (73) | 119 | (80) | 179 | (74) | 82 | (89) | 0.030 | |
Chest X-ray | Original scenario | 51 | (77) | 66 | (47)** | 88 | (58)* | 119 | (60)** | 67 | (73) | < 0.001 |
Family’s appeal | 44 | (67) | 61 | (43)* | 74 | (49)* | 29 | (38)** | 59 | (65) | < 0.001 | |
Advance directive | 59 | (88) | 111 | (79) | 124 | (83) | 194 | (81) | 90 | (98)* | 0.001 | |
Laboratory tests | Original scenario | 49 | (74) | 70 | (59)* | 87 | (57)* | 121 | (50)* | 59 | (64) | 0.002 |
Family’s appeal | 40 | (61) | 60 | (43)* | 67 | (45)* | 85 | (35)** | 51 | (56) | < 0.001 | |
Advance directive | 58 | (87) | 115 | (81) | 119 | (78) | 190 | (78) | 88 | (96)* | 0.006 |
Trajectory analysis and factors associated with aggressive treatment decisions
Univariate | Age-adjusted | Multivariate | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
n | OR | (95% CI) | p | OR | (95% CI) | p | OR | (95% CI) | p | |
Age continuous, years | 692 |
0.96
|
(0.95–0.98)
| < 0.001 | ||||||
Age | < 0.001 | 0.002 | ||||||||
25–35 | 52 |
4.71
|
(2.35–9.44)
|
3.19
|
(1.54–6.57)
| |||||
35–49 | 253 |
1.49
|
(1.08–2.05)
|
1.46
|
(1.03–2.06)
| |||||
50–67 | 387 | 1.00 | 1.00 | |||||||
Sex | 0.796 | 0.433 | ||||||||
Female | 425 | 1.04 | (0.77–1.41) | 0.88 | (0.64–1.21) | |||||
Male | 267 | 1.00 | 1.00 | |||||||
Chief-position | 0.013 | 0.208 | ||||||||
No | 480 |
1.51
|
(1.09–2.11)
| 1.25 | (0.88–1.76) | |||||
Yes | 205 | 1.00 | 1.00 | |||||||
Financial responsibility | 0.006 | 0.083 | 0.183 | |||||||
No | 562 |
1.75
|
(1.17–2.62)
|
1.44
|
(0.95–2.19)
| 1.35 | (0.87–2.08) | |||
Yes | 120 | 1.00 | 1.00 | 1.00 | ||||||
Own advance directive | 0.604 | 0.932 | ||||||||
No | 638 | 1.17 | (0.65–2.09) | 1.03 | (0.57–1.86) | |||||
Yes | 49 | 1.00 | 1.00 | |||||||
End-of-life care among relatives | 0.066 | 0.322 | ||||||||
No | 336 |
1.32
|
(0.98–1.79)
| 1.17 | (0.86–1.59) | |||||
Yes | 352 | 1.00 | 1.00 | |||||||
Physician group | < 0.001 | < 0.001 | < 0.001 | |||||||
Competency in PM | 66 | 1.00 | 1.00 | 1.00 | ||||||
Oncologists | 92 | 1.63 | (0.78–3.40) | 1.39 | (0.66–2.93) | 1.61 | (0.75–3.46) | |||
Internists | 150 |
3.92
|
(2.00–7.67)
|
3.85
|
(1.96–7.57)
|
4.27
|
(2.13–8.56)
| |||
Surgeons | 142 |
4.53
|
(2.30–8.90)
|
4.37
|
(2.21–8.64)
|
4.51
|
(2.25–9.07)
| |||
GPs | 242 |
6.27
|
(3.29–12.0)
|
5.34
|
(2.78–10.3)
|
5.60
|
(2.85–11.0)
|