PATIENT AND PHYSICIAN PERCEPTIONS OF LIFE-SUSTAINING INTERVENTIONS

Purpose
Physicians and patients may have different perceptions of life-sustaining interventions (LSI) regarding their character and appropriate use due to varying experience levels with these interventions which may present challenges to end-of-life decision-making. Different perceptions may present challenges when physicians discuss LSI with patients or surrogate decision-makers.

Methods
Physicians and patients at an academic medical center were surveyed regarding perceived willingess to withhold or withdraw LSI and perceived aggressiveness of LSI. Willingness to withhold or withdraw was assessed by identifying which LSI the subject would withdraw first in a hypothetical end-of-life scenario of pneumonia requiring mechanical ventilation among 21 pairwise combinations of the following LSI: cardiopulmonary resuscitation (CPR), indefinite mechanical ventilation (IMV), limited mechical ventilation (LMV), surgery, hemodialysis, artificial hydration and nutrition (AHN), and antibiotics. Perceived aggressiveness of LSI was determined by asking subjects to generate serial rankings of the LSI from least to most aggressive. Willingness to withhold or withdraw the LSI in the scenario-based comparisons was determined using a Bradley-Terry model. The serial rankings were evaluated using the Friedman test followed by pairwise comparisons.

Results
Twenty-nine physicians and fifty patients were interviewed. In the scenario, physicians were not more likely to withdraw LMV over antibiotics (OR 1.13, 95% CI 0.65-1.98) but were significantly more likely to withhold or withdraw in ascending order AHN (OR 3.31, 95% CI 1.94-5.64), hemodialysis (OR 4.012, 95% CI 2.34-6.87), surgery (OR 8.68, 95% CI 4.95-15.22), CPR (OR 12.15, 95% CI 6.80-21.72), and IMV (OR 13.08, 95% CI 7.30-23.46). Patients were only more likely to withdraw IMV over antibiotics (OR 2.03, 95% CI 1.48-2.78). Physicians’ serial rankings of LSI aggressiveness followed the same stepwise pattern and were more discretely distinguished across the full range of rankings than were patients' rankings. Patients' rankings were much more clustered around the mean ranking.

Conclusion
Physicians demonstrated a fairly strong consensus regarding their willingness to withhold and withdraw LSI which corresponded to their perceptions of the aggressiveness of LSI. Patients displayed less consistency in their choices regarding the withholding or withdrawal of LSI and in their ranking of the aggressiveness of LSI. Physicians should recognize that patients have limited understanding of LSI when engaging in end-of-life decision-making conversations with patients. Simply inquiring about the desire for LSI may be inadequate for meaningful decision-making.