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

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. Keywords: Clinical ethics, Decision-making, End-of-life care, Euthanasia Background government is currently considering options after a civil Discussions about the ethical justification of hastened motion demanding the legalization of euthanasia. At death due to unbearable suffering are ongoing. Assisted thesametime, theimportanceof palliative careand death through euthanasia or physician-assisted suicide patient-centred decision- making has been increasingly (PAS) has been legalized in seven countries (five states recognized among health care professionals and the gen- in the United States of America) thus far [1]. In addition, eral public in European countries including Finland [3–9]. public support for euthanasia and PAS is mounting all Palliative care, by definition, intends to neither hasten over Western Europe, while some decline has been ob- nor postpone death [10]. The International Association for served in the United States of America and Eastern Europe Hospice and Palliative Care and the European Association [1, 2]. Today, there are debates about the legalization of for Palliative Care have recently stated that euthanasia and euthanasia in many countries, including Finland, where the PAS should not be included as part of the clinical practice of palliative care [11, 12]. Attitudes among physicians towards assisted death are not widely studied, but sev- * Correspondence: piili.reetta.p@student.uta.fi Faculty of Medicine and Life Sciences, University of Tampere, Tampere, eral surveys do demonstrate a lower amount of support Finland from physicians for euthanasia and PAS when com- Department of Oncology, Palliative Care Unit, Tampere University Hospital, pared to support from the general public [1]. Teiskontie 35, R-building, 33520 Tampere, Finland Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Piili et al. BMC Medical Ethics (2018) 19:40 Page 2 of 10 Questions about hastening death in end-of-life care with a 100-mm visual analogue scale (VAS) from “definitely are complex and may include ethical concerns broader agree” (0 mm) to “definitely disagree” (100 mm). These than just euthanasia or PAS. Although clear definitions included, for example, statements concerning euthanasia, have been specified for euthanasia and PAS [12], which palliative care, the role of religion in ethical decisions, ad- lead to a clearly assisted death, the term “hastened death” vanced care directives and health care economics together is unspecified and has many interpretations. The termin- with physicians’ satisfaction with their own health, work ation of life-sustaining treatments may be confused with and salary (Tables 2 and 3). Physicians’ personal concep- euthanasia and PAS among the public and physicians [13]. tions of professional status and their own health, family life, The term “double effect” has been used when the act religion, and nature and standard of living were assessed intended to do good (e.g., relief of suffering) justifies the using a four-point Likert scale (Table 2). The questionnaire foreseeable danger of harm (e.g., hastened death) [14]. has been previously used and validated with Finnish physi- The use and dosing of opioids during end-of-life care is a cians [24–26]. commonly used example when talking about the double effect: does the intent to treat pain or breathlessness out- Patient scenarios weigh the risk of potentially hastening death [15, 16]? In this study, we included two patient scenarios: However, there is growing evidence that even though high doses of opioids may cause respiratory depression In scenario 1, a 60-year-old male patient is suffering [17–19], they do not seem to hasten death during from prostatic cancer with metastases. Metastases in end-of-life care [20, 21]. In a large multinational study the thoracic spine led to total paraparesis 1 month by Miccinesi et al., there was general approval for alle- earlier. There is no hope for a cure. The patient is viating symptoms with a possibly life-shortening treat- well aware of the situation. He has totally lost his ment [22]. In another study from the United Kingdom will to live. When you are together with him alone, (UK), physicians reported that they had at least some he asks for a sufficient dose of morphine to “get intention to hasten death in 7.4% of the deaths evalu- away”. You have denied the overdose, explaining that ated [23]. Physicians’ attitudes towards hastened death it is against your ethical principles. During the fol- through a dual effect and the background factors influ- lowing days, you notice that the patient asks you to encing these decisions remain largely unknown. double his morphine dose because of unbearable The aims of our study were to elucidate how, if at all, pain. The anti-inflammatory pain medication is at its the attitudes and values towards assisted death among maximum dose and you suspect if the pain is real Finnish physicians have changed over the past 16 years (this sentence was removed from the scenario in and to determine the attitudes and background factors 2015 as it did not comply with current treatment affecting physicians’ willingness to accept hastened death guidelines for cancer pain). You suppose that in- in a hypothetical patient scenario. creasing the dose in such a way would lead to the patient’s death. Your decision is which of the follow- Methods ing: a) to raise the dose because the patient has the Participants right to sufficient pain relief in this end-of-life (ter- A postal survey was conducted in spring 1999 and in minal) care situation; b) to try to help the patient in autumn 2015. In both years, the questionnaire was sent other ways, such as with antidepressants, thus con- to 500 general practitioners (GPs), 300 surgeons, and tinuing with morphine dosing according to given 300 internists randomly selected from the register of guidelines; c) I can’tsay; ord) give another the Finnish Medical Association and to all Finnish oncolo- solution:_______________________. gists (n= 82in1999and n = 158 in 2015). Reminders were sent twice to non-respondents. A cover letter including an introduction to the study and an assurance of anonymity In scenario 2, a 32-year-old female patient is brought was mailed together with the questionnaire. It was also by ambulance to the emergency unit. She is accompanied stated in the cover letter, that answering to the question- by her husband who says his wife has inoperable brain naire was completely voluntary. This study was approved cancer. She has been receiving maximum radiotherapy, by the Regional Ethics Committee of Tampere University but this was discontinued 3 weeks ago. She has deterio- Hospital, Finland (R15101). rated considerably during the past week. The patient has now had an epileptic seizure and has been unconscious Questionnaire since the attack. After 20 min at the hospital the patient The questionnaire included seven hypothetical patient stops breathing, and there is no pulse. Your treatment scenarios. Following the patient scenarios, attitudes re- decision is which of the following: a) to start cardiopul- garding several moral and ethical aspects were assessed monary resuscitation (CPR) or b) to withhold CPR. Piili et al. BMC Medical Ethics (2018) 19:40 Page 3 of 10 Statistical analysis Change in decision-making The answers concerning the doubling of the morphine dose In the case in scenario 1, physicians were significantly in scenario 1 were converted to two options: “I accept” (re- more willing to increase the morphine dose in 2015 sponse a) and “I do not accept” (other solutions). The an- (n = 219, 34%) than in 1999 (n = 180, 25%) (p < 0.001). swers on the 4- point Likert scale concerning values were This willingness increased in all groups of physicians, converted to the following 2-point scale: 1–2for “not except among oncologists, who were also the most important” and 3–4for “important”. unwilling to do this in both years (Fig. 1). In contrast, Two-scale background factors and values were tested 84% of the physicians decided to withhold CPR in case sce- using the Pearson chi-square test. nario 2 in both years. There were no significant changes Continuous variables were tested using an indepen- regarding this decision about CPR among the different dent-variables t-test or the Mann-Whitney U- test if the data physician groups between the study years. were not normally distributed. Two-sided p-values less than 0.05 were considered as statistically significant. Factors associated with physicians’ willingness to increase the morphine dose Difference in the attitudes of physicians who accepted Logistic regression analysis and those who did not accept the doubling of the mor- A forward stepwise logistic regression was used to create phine dose in both years studied are shown in Table 3. a model explaining the decision to increase the morphine In 1999, leniency towards euthanasia and assisted sui- dose. Background factors, life values, and attitudes, shown cide was significantly greater in those who accepted the in Table 2, were all included in the model. The p-value dose increase, while this was true only for assisted suicide limit for significance was set at 0.10 to enter and 0.15 to in 2015. remove from the model. Religion had a significantly larger influence on Data analyses were performed using IBM SPSS Statis- decision-making in physicians who accepted the mor- tics for Windows, Version 23.0 (Armonk, NY: IBM Corp. phine dose increase in 1999 but not in 2015. Released 2014). Factors and attitudes that independently influenced physicians’ willingness to increase the morphine dose from the logistic regression analysis are shown in Table 4. Results Not being an oncologist was the most striking factor In total, 1373 valid responses were received (response associated with physicians’ willingness to increase the rate 56%). Characteristics of the physicians according morphine dose. In addition, physicians who were male, to the year of response are shown in Table 1.Com- were older, did not believe in God, accepted assisted sui- pared to respondents in 1999, respondents in 2015 cide, had doubts about physicians’ ability to assess cancer were older (p < 0.001), had longer working experience pain, and responded in 2015 were also more likely to be (p < 0.001) and were more often women (p <0.001). willing to increase the morphine dose. However, physicians’ decisions about CPR for the patient in scenario 2 and Change in attitudes their attitudes towards euthanasia or withdrawal of The attitudes, personal factors and life values of the life-sustaining treatments did not influence their deci- responding physicians in 1999 and 2015 are shown sion to accept the escalation of the morphine dose. in Table 2. Euthanasia and withdrawal of life-sustaining treatments Discussion were considered slightly less reprehensible in 2015 than in Our study shows that some Finnish physicians’ attitudes 1999, whereas attitudes towards assisted suicide did not and life values have changed substantially during the last change significantly. In 2015, physicians more often be- 16 years. Their approval of euthanasia has slightly in- lieved that good palliative care enables a good death and creased, whereas their acceptance of physician-assisted found end-of-life care satisfying, although they were less suicide (PAS) has remained low. In an end-of-life patient often actually involved in end-of-life care than the respon- case scenario, physicians show an increasing willingness dents in 1999. Advance directives were considered more to give a high morphine dose, which might potentially helpful in 2015, although physicians still rarely had their hasten death. In logistic regression analysis, not being an own advance directives. The impact of physicians’ back- oncologist, being male, and not believing in God were ground factors, faith in God, and religion on ethical deci- the most important background factors associated with sions decreased between 1999 and 2015. The length of physicians’ willingness to increase the morphine dose. life, family, and cleanliness of environment were thought In our study Finnish physicians were less opposed to to be more important in 2015, while success in their pro- euthanasia now than they were 16 years ago. This find- fessional career was less important. ing is in agreement with previous studies showing Piili et al. BMC Medical Ethics (2018) 19:40 Page 4 of 10 Table 1 Characteristics of the participants Surgeons Internists GPs Oncologists Total 1999 2015 1999 2015 1999 2015 1999 2015 1999 2015 Number (% of total) 175 (24) 142 (22) 184 (25) 153 (24) 316 (43) 245 (38) 54 (7) 104 (16) 729 (100) 644 (100) Response rate, % 58 47 61 47 63 49 51 66 62 51 Female, n (%) 33 (19) 47 (33) 60 (33) 81 (53) 170 (55) 173 (71) 30 (56) 85 (82) 293 (41) 386 (60) Mean age (range) 48 (33–66) 51 (33–64) 48 (32–70) 52 (33–65) 42 (25–63) 47 (25–65) 46 (35–61) 48 (32–67) 45 (25–70) 50 (25–67) Working place Outpatient unit 1 (1) 2 (1) 15 (9) 15 (10) 242 (78) 208 (86) 2 (4) 4 (4) 260 (37) 229 (36) Hospital 146 (85) 124 (88) 123 (71) 122 (82) 33 (11) 24 (10) 44 (83) 91 (88) 346 (49) 361 (57) Other 24 (14) 15 (11) 35 (20) 12 (8) 35 (11) 10 (4) 7 (13) 8 (8) 101 (14) 45 (7) Years from graduation, 22 (2–42) 26 (7–42) 21 (7–41) 26 (8–42) 16 (1–35) 21 (0–40) 18 (9–34) 22 (7–40) 19 (1–42) 23 (0–42) median (range) Married, n (%) 140 (81) 119 (84) 142 (79) 124 (81) 228 (73) 198 (81) 45 (83) 71 (71) 555 (77) 512 (80) For 32 participants working place was not available For 19 participants year of graduation was not available GP general practitioner Piili et al. BMC Medical Ethics (2018) 19:40 Page 5 of 10 Table 2 Attitudes, background factors and life values of the physicians in 1999 and 2015 1999 2015 P-values* Attitudes, median VAS (IQR) Active euthanasia is reprehensible 17 (6–51) 25 (5–66) 0.008 Withdrawal of life-sustaining treatments is reprehensible 89 (76–95) 93 (76–99) < 0.001 Assisted suicide is reprehensible 14 (5–38) 13 (2–52) 0.480 End-of-life care is satisfying 36 (19–52) 15 (3–35) < 0.001 People should pay costs of factitious diseases by themselves 44 (27–72) 78 (46–93) < 0.001 Advance directives have been helpful in my decisions 35 (14–54) 10 (2–29) < 0.001 Good palliative care enables good death 17 (9–28) 4 (1–12) < 0.001 Physicians can’t estimate cancer pain 40 (25–70) 47 (27–72) 0.042 Religion has influence when I make ethical decisions 65 (31–93) 81 (47–98) < 0.001 Being a doctor gives me satisfaction 20 (11–30) 7 (2–18) < 0.001 My health is excellent 20 (10–32) 14 (6–26) < 0.001 I feel burn out, tired to work 84 (63–94) 89 (71–97) < 0.001 I’m pleased with my salary 72 (37–87) 22 (7–50) < 0.001 It is waste of resources to treat patients > 80 years in ICU 73 (49–86) 77 (54–93) < 0.001 Background factors and life values, n (%) Having children 600 (85) 555 (88) 0.057 Having own advance directive 38 (5) 38 (6) 0.668 Taking care of end-of-life patients in practice (last 2 years) 529 (75) 418 (65) < 0.001 Taking care of a family member in end-of-life 513 (73) 314 (49) < 0.001 Being afraid of death (Fear-of-death index) 580 (80) 544 (86) 0.006 Length of life is important 412 (59) 524 (87) < 0.001 Health is important 711 (99) 610 (99) 0.027 Family is important 686 (95) 607 (99) < 0.001 Clean environment is important 666 (93) 599 (98) < 0.001 High standard of living is important 358 (50) 398 (65) < 0.001 Faith in God is important 338 (48) 253 (42) 0.024 Success in professional career is important 639 (89) 377 (62) < 0.001 VAS visual analogue scale IQR interquartile range ICU intensive care unit *Mann-Whitney u-test for attitudes and Pearson Chi-Square for background factors and life values Attitudes are expressed on a visual analogue scale (VAS) from 0 mm (definitely agree) to 100 mm (definitely disagree) increased acceptance of euthanasia in Europe as well as 8 mm. Thus, our results highlight the controversial atti- in Finland [1, 2]. However, attitudes towards euthanasia tude towards euthanasia, which might not be found in were measured with a continuous visual analogue scale earlier studies; for example, a previous study showed (VAS) on a scale from 0 mm (reprehensible) to 100 mm that 46% of Finnish physicians supported legalization of (not reprehensible) in our study rather than with a di- euthanasia [2]. chotomous question (i.e., if the physician accepts or does In contrast to other studies [1], Finnish physicians not accept euthanasia). considered PAS even more reprehensible than euthan- Although using a VAS scale might have caused some asia and this has not changed at all during the past 16 confusion, doctors are generally familiar with its use. years. Determining whether this somewhat conflicting This type of assessment might provide more appropriate result is due to a true difference in the attitudes towards insight into this complex ethical question. Of note, the these two procedures or just less knowledge about the VAS median value in 2015 was still only 25 mm and the process of PAS in Finland could be an aim of future absolute difference compared to the value in 1999 was research. Piili et al. BMC Medical Ethics (2018) 19:40 Page 6 of 10 Fig. 1 Proportion of respondents who were willing to increase the morphine dose among different physician groups in 1999 and 2015 We asked if euthanasia or assisted suicide were repre- According to this study, Finnish physicians do not hensible or not with a VAS scale to evaluate the personal consider withdrawal of life-supporting treatments repre- ethical attitudes of the physicians rather than their opin- hensible. Although there was a statistically significant ions on the general justification of these issues. Therefore, change between the study years, the absolute difference our results represent somewhat different aspect of these was only 4 mm. Our results are in line with the results issues compared to the findings of studies that inquired from a large, international study by Löfmark et al. where about physicians’ opinions on the legalization of euthan- 72–86% of the physicians surveyed reported experien- asia or PAS. This might partly explain the differences in cing foregoing life-supporting treatment and only 1–6% the results of the present and previous studies [1, 2]. reported never being willing to do so [27]. Table 3 Attitudes of physicians who were willing or unwilling to increase the morphine dose in 1999 and 2015 1999 2015 Increasing the morphine dose Increasing the morphine dose Attitudes, median VAS (IQR) Yes No P-value* Yes No P-value* Active euthanasia is reprehensible 37 (11–69) 14 (5–39) < 0.001 33 (5–72) 24 (4–64) 0.162 Withdrawal of life-sustaining treatments is reprehensible 92 (83–96) 88 (72–95) 0.003 95 (80–99) 93 (75–98) 0.133 Assisted suicide is reprehensible 27 (9–61) 11 (4–28) < 0.001 28 (2–68) 10 (1–49) < 0.001 End-of-life care is satisfying 38 (19–51) 34 (18–52) 0.683 16 (2–30) 14 (3–45) 0.363 People should pay costs of factitious diseases by themselves 40 (23–65) 47 (29–75) 0.047 78 (49–94) 77 (47–93) 0.341 Advance directives have been helpful in my decisions 31 (10–55) 36 (15–54) 0.199 12 (2–29) 10 (2–28) 0.723 Good palliative care enables good death 19 (10–25) 16 (9–29) 0.833 4 (1–13) 4 (1–13) 0.869 Physicians can’t estimate cancer pain 35 (22–70) 41 (27–71) 0.056 44 (23–69) 50 (29–74) 0.006 Religion has influence when I make ethical decisions 77 (44–94) 57 (30–92) 0.040 86 (49–98) 78 (45–98) 0.130 Being a doctor gives me satisfaction 21 (11–29) 19 (11–30) 0.456 7 (1–19) 7 (2–18) 0.928 My health is excellent 21 (10–35) 20 (10–31) 0.273 15 (5–27) 14 (06–25) 0.751 I feel burn out, tired to work 84 (68–93) 84 (62–94) 0.701 88 (75–96) 89 (70–97) 0.843 I’m pleased with my salary 77 (51–90) 70 (35–87) 0.082 22 (8–50) 22 (7–51) 0.759 It is waste of resources to treat patients over 80 years of 70 (48–86) 73 (49–87) 0.262 82 (54–94) 75 (54–91) 0.107 age in ICU VAS visual analogue scale IQR interquartile range ICU intensive care unit *Mann-Whitney U-test Attitudes expressed on a visual analogue scale (VAS) from 0 mm (definitely agree) to 100 mm (definitely disagree) Piili et al. BMC Medical Ethics (2018) 19:40 Page 7 of 10 Table 4 Different background factors, life values and attitudes explaining physicians’ decision to increase the morphine dose (n = 323) versus not (n = 767) in forward logistic regression analysis n OR (95% CI) P-value Year of the survey 1999 578 ref. 2015 512 1.40 (1.05, 1.88) 0.024 Sex Female 534 ref. Male 556 1.51 (1.11, 2.05) 0.009 Age 1090 1.02 (1.01, 1.04) 0.007 Own advance directive No 1026 ref. Yes 64 1.74 (1.00, 3.03) 0.051 Faith in God Important 489 ref. Not important 601 1.64 (1.23, 2.19) 0.001 Assisted suicide is reprehensible (VAS) 1090 1.13 (1.08, 1.19) < 0.001 Physicians can’t estimate cancer pain (VAS) 1090 0.94 (0.89, 0.99) 0.021 Physician groups 0.014 Oncologists 120 ref. Surgeons 252 2.50 (1.40, 4.46) 0.002 Internists 268 2.37 (1.34, 4.20) 0.003 GPs 450 2.30 (1.33, 3.97) 0.003 ref, reference VAS, visual analogue scale GP, general practitioner Knowledge about the benefits of palliative care has In general, physicians accepted potentially lethal mor- grown in recent decades, and it is considered a part of phine dosing more frequently now than in 1999, although everyday care in life-threatening illnesses [10, 28, 29]. approximately two-thirds of the doctors were still unwilling Therefore, it is not surprising that almost all of the re- to provide this. This result might be due to actual accept- spondents in 2015 considered palliative care as a way of ance of hastening death at the end-of-life, better knowledge enabling a good death. However, in another study only regarding the use of opioids or both. It is now known that 51–70% of physicians believed that palliative care was clinically relevant respiratory failure is not a problem when able to prevent the need for euthanasia and PAS [22]. opioids are titrated against cancer pain [35]. Since 1999, Although advanced care planning has shown a positive there has been growing evidence that the use of opioids for impact on the quality of end-of-life care [30, 31], the symptom control in advanced diseases has no effect on sur- prevalence of advance directives varies largely. In the vival and even high doses of opioids do not seem to shorten United States, the prevalence of advance directives seems life during end-of-life care [20, 21]. In a study conducted in to have increased from approximately 10% up to 21–55% the Netherlands, physicians administered similar dosages of among the elderly in the last 10 years [32, 33], while a opioids in 1995, 2001 and 2005; however, compared Finnish study from 2004 showed that only 12% of the with previous years, in 2005, they thought that life was home-dwelling elderly had a living will [34]. In our study, shortened by opioids or their intension was to hasten physicians found the advance directives of the patients death by administering opioids less frequently [16]. On now more helpful than they were in 1999, but having an the other hand, high doses of opioids do cause respiratory advance directive of their own was still uncommon among depression [17–19], and the potential of opioid to hasten doctors in 2015 even though they were older and more death during end-of-life care is almost impossible to study experienced than in 1999. This finding might reflect a with prospective randomized trials. Although we did not division between personal life values and experiences ask the intention behind physicians’ willingness to increase in clinical work. the morphine dose, it was clearly stated in the patient Piili et al. BMC Medical Ethics (2018) 19:40 Page 8 of 10 scenario that increasing the dose might lead to the patient’s why age and sex are related to the tendency to administer death. Oncologists were most reluctant to provide the dose potentially lethal morphine dose in our study remains un- increase, and their opinion did not change between 1999 known, but perhaps more experienced physicians do not and 2015. However, they were probably the most familiar believe that such a morphine dose would actually kill with the influences of opioids in clinical practice as well as the patient. Furthermore, men are reported to approve the studies on this issue. Our results reflect that surgeons, of assisted death more often than women in the general internists and GPs have become increasingly willing to has- population [1]. ten death according to a patient’s wishes today than they Developments in medicine have allowed many interven- were 16 years ago, although improved knowledge on the tions for patients with very advanced diseases, but the low low risk of using opioids during end-of-life care probably survival rates for cardiopulmonary resuscitation (CPR) in influenced our results. the cancer population have not changed [37]. Further- Our results are in line with the study by Miccinesi et al. more, advanced care planning, which increases the preva- in which oncologists were the least in favour of using lence of do-not-resuscitate orders, is probably a more lethal drugs [22]. In our study, the difference between common practice today than in the 1990’s[31, 38]. In our oncologists and other physician groups remained in the study, physicians’ willingness to start CPR in a patient results of the logistic regression analysis. These findings with very advanced cancer was relatively low and did not might be observed because oncologists take care of these change over the study years, in a contrast to the more eth- patients on a more regular basis and are perhaps aware ically difficult and complex attitude regarding hastening that a patient’s wish to hasten death does not always imply death. Of interest, the decision about CPR did not influ- a genuine wish to die, but might be the result of over- ence physicians’ willingness to hasten death through the whelming emotional suffering [36], which could be re- dual effect of a high morphine dose. We suggest that phy- lieved by therapy. sicians’ willingness to hasten death is mainly related to Religion has been confirmed to have a tremendous their personal attitudes and values rather than medical effect on end-of-life decisions and attitudes towards facts, which probably guide the decision to withhold CPR. euthanasia and PAS [1, 22, 27]. In the present study, Finally, we should state that changes in the surrounding faith in God was also found to decrease physicians’ will- society, general attitudes and clinical decision-making in ingness to administer potentially lethal morphine dose. Finland and Europe since the 1990s might have had a sub- The number of physicians who had faith in God is lower stantial influence on our results. In a large international in the present survey than in 1999, which might be one study, the use of lethal doses of drugs after the explicit re- reason for the increasing support for euthanasia and has- quest of a patient with a terminal illness and uncontrolled tened death. In a previously mentioned study, Löfmark et symptoms was accepted by 35–78% of physicians, depend- al. concluded that a non-religious philosophy of life ing on the country [22]. This large range describes the cul- increased physicians’ willingness to perform euthanasia tural influence on the difficult decision to hasten death, and PAS, possibly by emphasizing patient autonomy [27]. but the numbers are quite similar to those found in our Advance directives were relatively uncommon among study. Public attitudes towards assisted death have chan- physicians, but having one seemed to increase the willing- ged since the 1990s to become more permissible, which ness to double the morphine dose; however, the influence has led to legalization of assisted death in some countries of advance directives did not quite reach statistical signifi- and increased political support for it in Finland [1, 2]. At cance in our logistic regression analysis. To our know- the same time, knowledge and awareness of palliative care ledge, the influence of doctors’ own advance directives on have grown in Finland through national and international end-of-life decisions has not been previously reported. recommendations [39–41]. However, this has happened We suggest that completing an advance directive for later than in some other European countries such as the oneself may lead to greater acceptance of death, even if UK [3, 4]. In addition, patient autonomy and shared de- this is hastened in a situation without hope for a cure. cision- making in treatment-choices are increasingly em- Male sex and older age were independently associated phasized as important ethical principles throughout with physicians’ willingness to double the morphine dose. Western countries [5, 6, 42]. Patients’ rights regarding treat- Previous studies on these factors are somewhat controver- ment decisions were incorporated into Finnish law in 1992, sial. Females have been shown to be less supportive towards and respecting the patient’swishesiscurrently oneofthe ending life without explicit request from the patient, but main principles in the ethical guidelines of the Finnish Med- also to be more supportive of alleviating pain and other ical Association [8, 9]. This social and cultural context to- symptoms regardless of the possible life-shortening effects gether with the shift from paternalism towards a more [22, 26]. In general, younger physicians accept PAS more patient-centred approach in clinical decision-making prob- often but are less willing to withdraw life-prolonging treat- ably influenced the responding physicians’ considerations on ments than older physicians [2, 22, 26]. The exact reasons the reprehensibility of hastened death and their willingness Piili et al. BMC Medical Ethics (2018) 19:40 Page 9 of 10 to comply with patients’ requests in the ethically complex Author details Faculty of Medicine and Life Sciences, University of Tampere, Tampere, situation in our study [6, 43]. Finland. Department of Oncology, Palliative Care Unit, Tampere University Hospital, Teiskontie 35, R-building, 33520 Tampere, Finland. Faculty of Social Strengths and limitations of the study Sciences, University of Tampere, Tampere, Finland. Rehabilitation Center Apila, Kangasala, Finland. Limitations of this study need to be acknowledged. Our response rate (56%) is a limitation even though our study Received: 7 November 2017 Accepted: 16 May 2018 population is large and the response rate is higher than that in many recent studies [44–46]. The study population is also a representative sample, as it reflects the overall References 1. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and distribution of specialities and gender among Finnish practices of euthanasia and physician-assisted suicide in the United States, physicians [47]. The follow-up period is long enough to Canada, and Europe. JAMA. 2016;316(1):79. detect relevant changes in attitudes and decision-making. 2. Louhiala P, Enkovaara H, Halila H, Palve H, Vanska J. Finnish physicians' attitudes towards active euthanasia have become more positive over the Answers to the hypothetical scenarios might differ from last 10 years. J Med Ethics. 2015;41(4):353–5. the decisions made in clinical practice, but these questions 3. Centeno C, Lynch T, Donea O. 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Autonomy, consent, and limiting healthcare costs. this practice. Oncologists were the most reluctant of all J Med Ethics. 2005;31(7):424–6. the specialists studied to hasten death. Euthanasia, but not 8. Finlex Data Bank. Laki potilaan asemasta ja oikeuksista. Potilaan assisted suicide, was considered slightly less reprehensible itsemääräämisoikeus. 12.8.1992/785, 6§. 1992. https://www.finlex.fi/fi/laki/ajantasa/ 1992/19920785. Accessed 21 Jan 2018. in 2015. Relieving suffering, while considering the justi- 9. The Finnish Medical Association: Lääkärin Etiikka (Physician's Ethic). 2013. fication to hasten death, is a complex ethical question. https://www.laakariliitto.fi/site/assets/files/1273/laakarin_etiikka_2013.pdf. Therefore, both training in medical ethics and medicine Accessed 22 Jan 2018. 10. World Health Organization. WHO Definition of Palliative Care. Geneva; 2002. are needed for high quality end-of-life care. http://www.who.int/cancer/palliative/definition/en/. Accessed 23 May 2017 11. De Lima L, Woodruff R, Pettus K, Downing J, Buitrago R, Munyoro E, Abbreviations Venkateswaran C, Bhatnagar S, Radbruch L. International Association for CPR: Cardiopulmonary resuscitation; GP: General practitioner; ICU: Intensive Hospice and Palliative Care Position Statement: euthanasia and physician- care unit; IQR: Interquartile range; PAS: Physician-assisted suicide; UK: the assisted suicide. J Palliat Med. 2017;20(1):8–14. United Kingdom; VAS: Visual analogue scale 12. Radbruch L, Leget C, Bahr P, Muller-Busch C, Ellershaw J, de Conno F, Vanden Berghe P, Board members of EAPC. Euthanasia and physician- Funding assisted suicide: a white paper from the European Association for Palliative This study was funded by the Seppo Nieminen Legacy Fund, the Signe and Care. Palliat Med. 2016;30(2):104–16. Ane Gyllenberg Foundation, the Finnish Medical Association and the Cancer 13. Lindblad A, Juth N, Furst CJ, Lynoe N. When enough is enough; terminating Society of Pirkanmaa. The funders did not have any role in the design of the life-sustaining treatment at the patient's request: a survey of attitudes among study; in the collection, analysis or interpretation of the data; or in the Swedish physicians and the general public. J Med Ethics. 2010;36(5):284–9. writing of the manuscript. 14. Billings JA. Double effect: a useful rule that alone cannot justify hastening death. J Med Ethics. 2011;37(7):437–40. Availability of data and materials 15. Cavanaugh TA. The ethics of death-hastening or death-causing palliative The datasets used and analysed during the study are available from the analgesic administration to the terminally ill. J Pain Symptom Manag. corresponding author on reasonable request. 1996;12(4):248–54. 16. Rurup ML, Borgsteede SD, van der Heide A, van der Maas PJ, Onwuteaka- Authors’ contributions Philipsen BD. Trends in the use of opioids at the end of life and the expected RP, JL, HH and PLKL designed the study outline and the questionnaire. RP, JL effects on hastening death. J Pain Symptom Manag. 2009;37(2):144–55. and PLKL collected the data. RP, JL, PLKL and RM analysed the data. RP and 17. Boom M, Niesters M, Sarton E, Aarts L, Smith TW, Dahan A. Non-analgesic RM performed the final statistical analysis. All the authors contributed to the effects of opioids: opioid-induced respiratory depression. Curr Pharm Des. writing and reviewing of the manuscript and approved the final manuscript. 2012;18(37):5994–6004. 18. Dahan A, Overdyk F, Smith T, Aarts L, Niesters M. Pharmacovigilance: a Ethics approval and consent to participate review of opioid- induced respiratory depression in chronic pain patients. The study was approved by the Regional Ethics Committee of Tampere Pain Physician. 2013;16(2):E85–94. University Hospital, Finland (R15101) and participation was voluntary and 19. Pattinson KT. Opioids and The control of respiration. Br J Anaesth. 2008; anonymous. 100(6):747–58. 20. Lopez-Saca JM, Guzman JL, Centeno C. A systematic review of the influence Competing interests of opioids on advanced cancer patient survival. Curr Opin Support Palliat The authors declare that they have no competing interests. Care. 2013;7(4):424–30. 21. Sykes N, Thorns A. The use of opioids and sedatives at the end of life. Publisher’sNote Lancet Oncol. 2003;4(5):312–8. Springer Nature remains neutral with regard to jurisdictional claims in 22. Miccinesi G, Fischer S, Paci E, Onwuteaka-Philipsen BD, Cartwright C, van der published maps and institutional affiliations. Heide A, Nilstun T, Norup M, Mortier F, EURELD consortium. Physicians' Piili et al. BMC Medical Ethics (2018) 19:40 Page 10 of 10 attitudes towards end-of-life decisions: a comparison between seven 44. Cartwright CM, White BP, Willmott L, Williams G, Parker MH. Palliative care countries. Soc Sci Med. 2005;60(9):1961–74. and other physicians' knowledge, attitudes and practice relating to the law 23. Seale C. Hastening death in end-of-life care: a survey of doctors. Soc Sci on withholding/withdrawing life- sustaining treatment: survey results. Palliat Med. 2009;69(11):1659–66. Med. 2016;30(2):171–9. 45. Escher M, Perneger TV, Rudaz S, Dayer P, Perrier A. Impact of advance 24. Hinkka H, Kosunen E, Metsanoja R, Lammi UK, Kellokumpu-Lehtinen P. To directives and a health care proxy on doctors' decisions: a randomized trial. resuscitate or not: a dilemma in terminal cancer care. Resuscitation. J Pain Symptom Manag. 2014;47(1):1–11. 2001;49(3):289–97. 46. Nakazawa K, Kizawa Y, Maeno T, Takayashiki A, Abe Y, Hamano J, 25. Hinkka H, Kosunen E, Lammi EK, Metsanoja R, Puustelli A, Kellokumpu- Maeno T. Palliative care physicians' practices and attitudes regarding Lehtinen P. Decision making in terminal care: a survey of finnish advance care planning in palliative care units in Japan: a nationwide doctors' treatment decisions in end-of-life scenarios involving a survey. Am J Hosp Palliat Care. 2014;31(7):699–709. terminal cancer and a terminal dementia patient. Palliat Med. 47. The Finnish Medical Association: Physicians in Finland, statistics on 2002;16(3):195–204. physicians and the health care system 2016. [https://www.laakariliitto. 26. Hinkka H, Kosunen E, Metsanoja R, Lammi UK, Kellokumpu-Lehtinen P. fi/site/assets/files/1268/ll16_tilasto2016_net1_170114.pdf]. Accessed 27 Factors affecting physicians' decisions to forgo life-sustaining treatments in December 2017. terminal care. J Med Ethics. 2002;28(2):109–14. 27. Löfmark R, Nilstun T, Cartwright C, Fischer S, van der Heide A, Mortier F, Norup M, Simonato L, Onwuteaka-Philipsen BD, EURELD Consortium. Physicians' experiences with end-of-life decision- making: survey in 6 European countries and Australia. BMC Med. 2008;6:4. 7015–6-4 28. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ. Early palliative care for patients with metastatic non- small-cell lung cancer. N Engl J Med. 2010;363(8):733–42. 29. Zimmermann C, Swami N, Krzyzanowska M, Hannon B, Leighl N, Oza A, Moore M, Rydall A, Rodin G, Tannock I, Donner A, Lo C. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721–30. 30. Houben CH, Spruit MA, Groenen MT, Wouters EF, Janssen DJ. Efficacy of advance care planning: a systematic review and meta-analysis. J Am Med Dir Assoc. 2014;15(7):477–89. 31. Brinkman-Stoppelenburg A, Rietjens JA, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med. 2014;28(8):1000–25. 32. Johnston SC. Advance directives: from the perspective of the patient and the physician. J R Soc Med. 1996;89(10):568–70. 33. Oulton J, Rhodes SM, Howe C, Fain MJ, Mohler MJ. Advance directives for older adults in the emergency department: a systematic review. J Palliat Med. 2015;18(6):500–5. 34. Laakkonen ML, Pitkala KH, Strandberg TE, Berglind S, Tilvis RS. Living will, resuscitation preferences, and attitudes towards life in an aged population. Gerontology. 2004;50(4):247–54. 35. Estfan B, Mahmoud F, Shaheen P, Davis MP, Lasheen W, Rivera N, Legrand SB, Lagman RL, Walsh D, Rybicki L. Respiratory function during parenteral opioid titration for cancer pain. Palliat Med. 2007;21(2):81–6. 36. Monforte-Royo C, Villavicencio-Chavez C, Tomas-Sabado J, Mahtani-Chugani V, Balaguer A. What lies behind the wish to hasten death? A systematic review and meta-ethnography from the perspective of patients. PLoS One. 2012;7(5):e37117. 37. Miller AH, Sandoval M, Wattana M, Page VD, Todd KH. 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Shared decision making: concepts, evidence, and practice. Patient Educ Couns. 2015;98(10):1172–9. 43. National Institute for Health and Care Excellence. Clinical Guidelines. Care of Dying Adults in the Last Days of Life. 2015. National Clinical Guideline Centre, London. https://www.nice.org.uk/guidance/ng31/ resources/care-of-dying-adults-in-the-last-days-of-life-%20pdf- 1837387324357. Accessed 18 Jan 2018. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Medical Ethics Springer Journals

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

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Philosophy; Ethics; Philosophy of Medicine; Theory of Medicine/Bioethics
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Abstract

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. Keywords: Clinical ethics, Decision-making, End-of-life care, Euthanasia Background government is currently considering options after a civil Discussions about the ethical justification of hastened motion demanding the legalization of euthanasia. At death due to unbearable suffering are ongoing. Assisted thesametime, theimportanceof palliative careand death through euthanasia or physician-assisted suicide patient-centred decision- making has been increasingly (PAS) has been legalized in seven countries (five states recognized among health care professionals and the gen- in the United States of America) thus far [1]. In addition, eral public in European countries including Finland [3–9]. public support for euthanasia and PAS is mounting all Palliative care, by definition, intends to neither hasten over Western Europe, while some decline has been ob- nor postpone death [10]. The International Association for served in the United States of America and Eastern Europe Hospice and Palliative Care and the European Association [1, 2]. Today, there are debates about the legalization of for Palliative Care have recently stated that euthanasia and euthanasia in many countries, including Finland, where the PAS should not be included as part of the clinical practice of palliative care [11, 12]. Attitudes among physicians towards assisted death are not widely studied, but sev- * Correspondence: piili.reetta.p@student.uta.fi Faculty of Medicine and Life Sciences, University of Tampere, Tampere, eral surveys do demonstrate a lower amount of support Finland from physicians for euthanasia and PAS when com- Department of Oncology, Palliative Care Unit, Tampere University Hospital, pared to support from the general public [1]. Teiskontie 35, R-building, 33520 Tampere, Finland Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Piili et al. BMC Medical Ethics (2018) 19:40 Page 2 of 10 Questions about hastening death in end-of-life care with a 100-mm visual analogue scale (VAS) from “definitely are complex and may include ethical concerns broader agree” (0 mm) to “definitely disagree” (100 mm). These than just euthanasia or PAS. Although clear definitions included, for example, statements concerning euthanasia, have been specified for euthanasia and PAS [12], which palliative care, the role of religion in ethical decisions, ad- lead to a clearly assisted death, the term “hastened death” vanced care directives and health care economics together is unspecified and has many interpretations. The termin- with physicians’ satisfaction with their own health, work ation of life-sustaining treatments may be confused with and salary (Tables 2 and 3). Physicians’ personal concep- euthanasia and PAS among the public and physicians [13]. tions of professional status and their own health, family life, The term “double effect” has been used when the act religion, and nature and standard of living were assessed intended to do good (e.g., relief of suffering) justifies the using a four-point Likert scale (Table 2). The questionnaire foreseeable danger of harm (e.g., hastened death) [14]. has been previously used and validated with Finnish physi- The use and dosing of opioids during end-of-life care is a cians [24–26]. commonly used example when talking about the double effect: does the intent to treat pain or breathlessness out- Patient scenarios weigh the risk of potentially hastening death [15, 16]? In this study, we included two patient scenarios: However, there is growing evidence that even though high doses of opioids may cause respiratory depression In scenario 1, a 60-year-old male patient is suffering [17–19], they do not seem to hasten death during from prostatic cancer with metastases. Metastases in end-of-life care [20, 21]. In a large multinational study the thoracic spine led to total paraparesis 1 month by Miccinesi et al., there was general approval for alle- earlier. There is no hope for a cure. The patient is viating symptoms with a possibly life-shortening treat- well aware of the situation. He has totally lost his ment [22]. In another study from the United Kingdom will to live. When you are together with him alone, (UK), physicians reported that they had at least some he asks for a sufficient dose of morphine to “get intention to hasten death in 7.4% of the deaths evalu- away”. You have denied the overdose, explaining that ated [23]. Physicians’ attitudes towards hastened death it is against your ethical principles. During the fol- through a dual effect and the background factors influ- lowing days, you notice that the patient asks you to encing these decisions remain largely unknown. double his morphine dose because of unbearable The aims of our study were to elucidate how, if at all, pain. The anti-inflammatory pain medication is at its the attitudes and values towards assisted death among maximum dose and you suspect if the pain is real Finnish physicians have changed over the past 16 years (this sentence was removed from the scenario in and to determine the attitudes and background factors 2015 as it did not comply with current treatment affecting physicians’ willingness to accept hastened death guidelines for cancer pain). You suppose that in- in a hypothetical patient scenario. creasing the dose in such a way would lead to the patient’s death. Your decision is which of the follow- Methods ing: a) to raise the dose because the patient has the Participants right to sufficient pain relief in this end-of-life (ter- A postal survey was conducted in spring 1999 and in minal) care situation; b) to try to help the patient in autumn 2015. In both years, the questionnaire was sent other ways, such as with antidepressants, thus con- to 500 general practitioners (GPs), 300 surgeons, and tinuing with morphine dosing according to given 300 internists randomly selected from the register of guidelines; c) I can’tsay; ord) give another the Finnish Medical Association and to all Finnish oncolo- solution:_______________________. gists (n= 82in1999and n = 158 in 2015). Reminders were sent twice to non-respondents. A cover letter including an introduction to the study and an assurance of anonymity In scenario 2, a 32-year-old female patient is brought was mailed together with the questionnaire. It was also by ambulance to the emergency unit. She is accompanied stated in the cover letter, that answering to the question- by her husband who says his wife has inoperable brain naire was completely voluntary. This study was approved cancer. She has been receiving maximum radiotherapy, by the Regional Ethics Committee of Tampere University but this was discontinued 3 weeks ago. She has deterio- Hospital, Finland (R15101). rated considerably during the past week. The patient has now had an epileptic seizure and has been unconscious Questionnaire since the attack. After 20 min at the hospital the patient The questionnaire included seven hypothetical patient stops breathing, and there is no pulse. Your treatment scenarios. Following the patient scenarios, attitudes re- decision is which of the following: a) to start cardiopul- garding several moral and ethical aspects were assessed monary resuscitation (CPR) or b) to withhold CPR. Piili et al. BMC Medical Ethics (2018) 19:40 Page 3 of 10 Statistical analysis Change in decision-making The answers concerning the doubling of the morphine dose In the case in scenario 1, physicians were significantly in scenario 1 were converted to two options: “I accept” (re- more willing to increase the morphine dose in 2015 sponse a) and “I do not accept” (other solutions). The an- (n = 219, 34%) than in 1999 (n = 180, 25%) (p < 0.001). swers on the 4- point Likert scale concerning values were This willingness increased in all groups of physicians, converted to the following 2-point scale: 1–2for “not except among oncologists, who were also the most important” and 3–4for “important”. unwilling to do this in both years (Fig. 1). In contrast, Two-scale background factors and values were tested 84% of the physicians decided to withhold CPR in case sce- using the Pearson chi-square test. nario 2 in both years. There were no significant changes Continuous variables were tested using an indepen- regarding this decision about CPR among the different dent-variables t-test or the Mann-Whitney U- test if the data physician groups between the study years. were not normally distributed. Two-sided p-values less than 0.05 were considered as statistically significant. Factors associated with physicians’ willingness to increase the morphine dose Difference in the attitudes of physicians who accepted Logistic regression analysis and those who did not accept the doubling of the mor- A forward stepwise logistic regression was used to create phine dose in both years studied are shown in Table 3. a model explaining the decision to increase the morphine In 1999, leniency towards euthanasia and assisted sui- dose. Background factors, life values, and attitudes, shown cide was significantly greater in those who accepted the in Table 2, were all included in the model. The p-value dose increase, while this was true only for assisted suicide limit for significance was set at 0.10 to enter and 0.15 to in 2015. remove from the model. Religion had a significantly larger influence on Data analyses were performed using IBM SPSS Statis- decision-making in physicians who accepted the mor- tics for Windows, Version 23.0 (Armonk, NY: IBM Corp. phine dose increase in 1999 but not in 2015. Released 2014). Factors and attitudes that independently influenced physicians’ willingness to increase the morphine dose from the logistic regression analysis are shown in Table 4. Results Not being an oncologist was the most striking factor In total, 1373 valid responses were received (response associated with physicians’ willingness to increase the rate 56%). Characteristics of the physicians according morphine dose. In addition, physicians who were male, to the year of response are shown in Table 1.Com- were older, did not believe in God, accepted assisted sui- pared to respondents in 1999, respondents in 2015 cide, had doubts about physicians’ ability to assess cancer were older (p < 0.001), had longer working experience pain, and responded in 2015 were also more likely to be (p < 0.001) and were more often women (p <0.001). willing to increase the morphine dose. However, physicians’ decisions about CPR for the patient in scenario 2 and Change in attitudes their attitudes towards euthanasia or withdrawal of The attitudes, personal factors and life values of the life-sustaining treatments did not influence their deci- responding physicians in 1999 and 2015 are shown sion to accept the escalation of the morphine dose. in Table 2. Euthanasia and withdrawal of life-sustaining treatments Discussion were considered slightly less reprehensible in 2015 than in Our study shows that some Finnish physicians’ attitudes 1999, whereas attitudes towards assisted suicide did not and life values have changed substantially during the last change significantly. In 2015, physicians more often be- 16 years. Their approval of euthanasia has slightly in- lieved that good palliative care enables a good death and creased, whereas their acceptance of physician-assisted found end-of-life care satisfying, although they were less suicide (PAS) has remained low. In an end-of-life patient often actually involved in end-of-life care than the respon- case scenario, physicians show an increasing willingness dents in 1999. Advance directives were considered more to give a high morphine dose, which might potentially helpful in 2015, although physicians still rarely had their hasten death. In logistic regression analysis, not being an own advance directives. The impact of physicians’ back- oncologist, being male, and not believing in God were ground factors, faith in God, and religion on ethical deci- the most important background factors associated with sions decreased between 1999 and 2015. The length of physicians’ willingness to increase the morphine dose. life, family, and cleanliness of environment were thought In our study Finnish physicians were less opposed to to be more important in 2015, while success in their pro- euthanasia now than they were 16 years ago. This find- fessional career was less important. ing is in agreement with previous studies showing Piili et al. BMC Medical Ethics (2018) 19:40 Page 4 of 10 Table 1 Characteristics of the participants Surgeons Internists GPs Oncologists Total 1999 2015 1999 2015 1999 2015 1999 2015 1999 2015 Number (% of total) 175 (24) 142 (22) 184 (25) 153 (24) 316 (43) 245 (38) 54 (7) 104 (16) 729 (100) 644 (100) Response rate, % 58 47 61 47 63 49 51 66 62 51 Female, n (%) 33 (19) 47 (33) 60 (33) 81 (53) 170 (55) 173 (71) 30 (56) 85 (82) 293 (41) 386 (60) Mean age (range) 48 (33–66) 51 (33–64) 48 (32–70) 52 (33–65) 42 (25–63) 47 (25–65) 46 (35–61) 48 (32–67) 45 (25–70) 50 (25–67) Working place Outpatient unit 1 (1) 2 (1) 15 (9) 15 (10) 242 (78) 208 (86) 2 (4) 4 (4) 260 (37) 229 (36) Hospital 146 (85) 124 (88) 123 (71) 122 (82) 33 (11) 24 (10) 44 (83) 91 (88) 346 (49) 361 (57) Other 24 (14) 15 (11) 35 (20) 12 (8) 35 (11) 10 (4) 7 (13) 8 (8) 101 (14) 45 (7) Years from graduation, 22 (2–42) 26 (7–42) 21 (7–41) 26 (8–42) 16 (1–35) 21 (0–40) 18 (9–34) 22 (7–40) 19 (1–42) 23 (0–42) median (range) Married, n (%) 140 (81) 119 (84) 142 (79) 124 (81) 228 (73) 198 (81) 45 (83) 71 (71) 555 (77) 512 (80) For 32 participants working place was not available For 19 participants year of graduation was not available GP general practitioner Piili et al. BMC Medical Ethics (2018) 19:40 Page 5 of 10 Table 2 Attitudes, background factors and life values of the physicians in 1999 and 2015 1999 2015 P-values* Attitudes, median VAS (IQR) Active euthanasia is reprehensible 17 (6–51) 25 (5–66) 0.008 Withdrawal of life-sustaining treatments is reprehensible 89 (76–95) 93 (76–99) < 0.001 Assisted suicide is reprehensible 14 (5–38) 13 (2–52) 0.480 End-of-life care is satisfying 36 (19–52) 15 (3–35) < 0.001 People should pay costs of factitious diseases by themselves 44 (27–72) 78 (46–93) < 0.001 Advance directives have been helpful in my decisions 35 (14–54) 10 (2–29) < 0.001 Good palliative care enables good death 17 (9–28) 4 (1–12) < 0.001 Physicians can’t estimate cancer pain 40 (25–70) 47 (27–72) 0.042 Religion has influence when I make ethical decisions 65 (31–93) 81 (47–98) < 0.001 Being a doctor gives me satisfaction 20 (11–30) 7 (2–18) < 0.001 My health is excellent 20 (10–32) 14 (6–26) < 0.001 I feel burn out, tired to work 84 (63–94) 89 (71–97) < 0.001 I’m pleased with my salary 72 (37–87) 22 (7–50) < 0.001 It is waste of resources to treat patients > 80 years in ICU 73 (49–86) 77 (54–93) < 0.001 Background factors and life values, n (%) Having children 600 (85) 555 (88) 0.057 Having own advance directive 38 (5) 38 (6) 0.668 Taking care of end-of-life patients in practice (last 2 years) 529 (75) 418 (65) < 0.001 Taking care of a family member in end-of-life 513 (73) 314 (49) < 0.001 Being afraid of death (Fear-of-death index) 580 (80) 544 (86) 0.006 Length of life is important 412 (59) 524 (87) < 0.001 Health is important 711 (99) 610 (99) 0.027 Family is important 686 (95) 607 (99) < 0.001 Clean environment is important 666 (93) 599 (98) < 0.001 High standard of living is important 358 (50) 398 (65) < 0.001 Faith in God is important 338 (48) 253 (42) 0.024 Success in professional career is important 639 (89) 377 (62) < 0.001 VAS visual analogue scale IQR interquartile range ICU intensive care unit *Mann-Whitney u-test for attitudes and Pearson Chi-Square for background factors and life values Attitudes are expressed on a visual analogue scale (VAS) from 0 mm (definitely agree) to 100 mm (definitely disagree) increased acceptance of euthanasia in Europe as well as 8 mm. Thus, our results highlight the controversial atti- in Finland [1, 2]. However, attitudes towards euthanasia tude towards euthanasia, which might not be found in were measured with a continuous visual analogue scale earlier studies; for example, a previous study showed (VAS) on a scale from 0 mm (reprehensible) to 100 mm that 46% of Finnish physicians supported legalization of (not reprehensible) in our study rather than with a di- euthanasia [2]. chotomous question (i.e., if the physician accepts or does In contrast to other studies [1], Finnish physicians not accept euthanasia). considered PAS even more reprehensible than euthan- Although using a VAS scale might have caused some asia and this has not changed at all during the past 16 confusion, doctors are generally familiar with its use. years. Determining whether this somewhat conflicting This type of assessment might provide more appropriate result is due to a true difference in the attitudes towards insight into this complex ethical question. Of note, the these two procedures or just less knowledge about the VAS median value in 2015 was still only 25 mm and the process of PAS in Finland could be an aim of future absolute difference compared to the value in 1999 was research. Piili et al. BMC Medical Ethics (2018) 19:40 Page 6 of 10 Fig. 1 Proportion of respondents who were willing to increase the morphine dose among different physician groups in 1999 and 2015 We asked if euthanasia or assisted suicide were repre- According to this study, Finnish physicians do not hensible or not with a VAS scale to evaluate the personal consider withdrawal of life-supporting treatments repre- ethical attitudes of the physicians rather than their opin- hensible. Although there was a statistically significant ions on the general justification of these issues. Therefore, change between the study years, the absolute difference our results represent somewhat different aspect of these was only 4 mm. Our results are in line with the results issues compared to the findings of studies that inquired from a large, international study by Löfmark et al. where about physicians’ opinions on the legalization of euthan- 72–86% of the physicians surveyed reported experien- asia or PAS. This might partly explain the differences in cing foregoing life-supporting treatment and only 1–6% the results of the present and previous studies [1, 2]. reported never being willing to do so [27]. Table 3 Attitudes of physicians who were willing or unwilling to increase the morphine dose in 1999 and 2015 1999 2015 Increasing the morphine dose Increasing the morphine dose Attitudes, median VAS (IQR) Yes No P-value* Yes No P-value* Active euthanasia is reprehensible 37 (11–69) 14 (5–39) < 0.001 33 (5–72) 24 (4–64) 0.162 Withdrawal of life-sustaining treatments is reprehensible 92 (83–96) 88 (72–95) 0.003 95 (80–99) 93 (75–98) 0.133 Assisted suicide is reprehensible 27 (9–61) 11 (4–28) < 0.001 28 (2–68) 10 (1–49) < 0.001 End-of-life care is satisfying 38 (19–51) 34 (18–52) 0.683 16 (2–30) 14 (3–45) 0.363 People should pay costs of factitious diseases by themselves 40 (23–65) 47 (29–75) 0.047 78 (49–94) 77 (47–93) 0.341 Advance directives have been helpful in my decisions 31 (10–55) 36 (15–54) 0.199 12 (2–29) 10 (2–28) 0.723 Good palliative care enables good death 19 (10–25) 16 (9–29) 0.833 4 (1–13) 4 (1–13) 0.869 Physicians can’t estimate cancer pain 35 (22–70) 41 (27–71) 0.056 44 (23–69) 50 (29–74) 0.006 Religion has influence when I make ethical decisions 77 (44–94) 57 (30–92) 0.040 86 (49–98) 78 (45–98) 0.130 Being a doctor gives me satisfaction 21 (11–29) 19 (11–30) 0.456 7 (1–19) 7 (2–18) 0.928 My health is excellent 21 (10–35) 20 (10–31) 0.273 15 (5–27) 14 (06–25) 0.751 I feel burn out, tired to work 84 (68–93) 84 (62–94) 0.701 88 (75–96) 89 (70–97) 0.843 I’m pleased with my salary 77 (51–90) 70 (35–87) 0.082 22 (8–50) 22 (7–51) 0.759 It is waste of resources to treat patients over 80 years of 70 (48–86) 73 (49–87) 0.262 82 (54–94) 75 (54–91) 0.107 age in ICU VAS visual analogue scale IQR interquartile range ICU intensive care unit *Mann-Whitney U-test Attitudes expressed on a visual analogue scale (VAS) from 0 mm (definitely agree) to 100 mm (definitely disagree) Piili et al. BMC Medical Ethics (2018) 19:40 Page 7 of 10 Table 4 Different background factors, life values and attitudes explaining physicians’ decision to increase the morphine dose (n = 323) versus not (n = 767) in forward logistic regression analysis n OR (95% CI) P-value Year of the survey 1999 578 ref. 2015 512 1.40 (1.05, 1.88) 0.024 Sex Female 534 ref. Male 556 1.51 (1.11, 2.05) 0.009 Age 1090 1.02 (1.01, 1.04) 0.007 Own advance directive No 1026 ref. Yes 64 1.74 (1.00, 3.03) 0.051 Faith in God Important 489 ref. Not important 601 1.64 (1.23, 2.19) 0.001 Assisted suicide is reprehensible (VAS) 1090 1.13 (1.08, 1.19) < 0.001 Physicians can’t estimate cancer pain (VAS) 1090 0.94 (0.89, 0.99) 0.021 Physician groups 0.014 Oncologists 120 ref. Surgeons 252 2.50 (1.40, 4.46) 0.002 Internists 268 2.37 (1.34, 4.20) 0.003 GPs 450 2.30 (1.33, 3.97) 0.003 ref, reference VAS, visual analogue scale GP, general practitioner Knowledge about the benefits of palliative care has In general, physicians accepted potentially lethal mor- grown in recent decades, and it is considered a part of phine dosing more frequently now than in 1999, although everyday care in life-threatening illnesses [10, 28, 29]. approximately two-thirds of the doctors were still unwilling Therefore, it is not surprising that almost all of the re- to provide this. This result might be due to actual accept- spondents in 2015 considered palliative care as a way of ance of hastening death at the end-of-life, better knowledge enabling a good death. However, in another study only regarding the use of opioids or both. It is now known that 51–70% of physicians believed that palliative care was clinically relevant respiratory failure is not a problem when able to prevent the need for euthanasia and PAS [22]. opioids are titrated against cancer pain [35]. Since 1999, Although advanced care planning has shown a positive there has been growing evidence that the use of opioids for impact on the quality of end-of-life care [30, 31], the symptom control in advanced diseases has no effect on sur- prevalence of advance directives varies largely. In the vival and even high doses of opioids do not seem to shorten United States, the prevalence of advance directives seems life during end-of-life care [20, 21]. In a study conducted in to have increased from approximately 10% up to 21–55% the Netherlands, physicians administered similar dosages of among the elderly in the last 10 years [32, 33], while a opioids in 1995, 2001 and 2005; however, compared Finnish study from 2004 showed that only 12% of the with previous years, in 2005, they thought that life was home-dwelling elderly had a living will [34]. In our study, shortened by opioids or their intension was to hasten physicians found the advance directives of the patients death by administering opioids less frequently [16]. On now more helpful than they were in 1999, but having an the other hand, high doses of opioids do cause respiratory advance directive of their own was still uncommon among depression [17–19], and the potential of opioid to hasten doctors in 2015 even though they were older and more death during end-of-life care is almost impossible to study experienced than in 1999. This finding might reflect a with prospective randomized trials. Although we did not division between personal life values and experiences ask the intention behind physicians’ willingness to increase in clinical work. the morphine dose, it was clearly stated in the patient Piili et al. BMC Medical Ethics (2018) 19:40 Page 8 of 10 scenario that increasing the dose might lead to the patient’s why age and sex are related to the tendency to administer death. Oncologists were most reluctant to provide the dose potentially lethal morphine dose in our study remains un- increase, and their opinion did not change between 1999 known, but perhaps more experienced physicians do not and 2015. However, they were probably the most familiar believe that such a morphine dose would actually kill with the influences of opioids in clinical practice as well as the patient. Furthermore, men are reported to approve the studies on this issue. Our results reflect that surgeons, of assisted death more often than women in the general internists and GPs have become increasingly willing to has- population [1]. ten death according to a patient’s wishes today than they Developments in medicine have allowed many interven- were 16 years ago, although improved knowledge on the tions for patients with very advanced diseases, but the low low risk of using opioids during end-of-life care probably survival rates for cardiopulmonary resuscitation (CPR) in influenced our results. the cancer population have not changed [37]. Further- Our results are in line with the study by Miccinesi et al. more, advanced care planning, which increases the preva- in which oncologists were the least in favour of using lence of do-not-resuscitate orders, is probably a more lethal drugs [22]. In our study, the difference between common practice today than in the 1990’s[31, 38]. In our oncologists and other physician groups remained in the study, physicians’ willingness to start CPR in a patient results of the logistic regression analysis. These findings with very advanced cancer was relatively low and did not might be observed because oncologists take care of these change over the study years, in a contrast to the more eth- patients on a more regular basis and are perhaps aware ically difficult and complex attitude regarding hastening that a patient’s wish to hasten death does not always imply death. Of interest, the decision about CPR did not influ- a genuine wish to die, but might be the result of over- ence physicians’ willingness to hasten death through the whelming emotional suffering [36], which could be re- dual effect of a high morphine dose. We suggest that phy- lieved by therapy. sicians’ willingness to hasten death is mainly related to Religion has been confirmed to have a tremendous their personal attitudes and values rather than medical effect on end-of-life decisions and attitudes towards facts, which probably guide the decision to withhold CPR. euthanasia and PAS [1, 22, 27]. In the present study, Finally, we should state that changes in the surrounding faith in God was also found to decrease physicians’ will- society, general attitudes and clinical decision-making in ingness to administer potentially lethal morphine dose. Finland and Europe since the 1990s might have had a sub- The number of physicians who had faith in God is lower stantial influence on our results. In a large international in the present survey than in 1999, which might be one study, the use of lethal doses of drugs after the explicit re- reason for the increasing support for euthanasia and has- quest of a patient with a terminal illness and uncontrolled tened death. In a previously mentioned study, Löfmark et symptoms was accepted by 35–78% of physicians, depend- al. concluded that a non-religious philosophy of life ing on the country [22]. This large range describes the cul- increased physicians’ willingness to perform euthanasia tural influence on the difficult decision to hasten death, and PAS, possibly by emphasizing patient autonomy [27]. but the numbers are quite similar to those found in our Advance directives were relatively uncommon among study. Public attitudes towards assisted death have chan- physicians, but having one seemed to increase the willing- ged since the 1990s to become more permissible, which ness to double the morphine dose; however, the influence has led to legalization of assisted death in some countries of advance directives did not quite reach statistical signifi- and increased political support for it in Finland [1, 2]. At cance in our logistic regression analysis. To our know- the same time, knowledge and awareness of palliative care ledge, the influence of doctors’ own advance directives on have grown in Finland through national and international end-of-life decisions has not been previously reported. recommendations [39–41]. However, this has happened We suggest that completing an advance directive for later than in some other European countries such as the oneself may lead to greater acceptance of death, even if UK [3, 4]. In addition, patient autonomy and shared de- this is hastened in a situation without hope for a cure. cision- making in treatment-choices are increasingly em- Male sex and older age were independently associated phasized as important ethical principles throughout with physicians’ willingness to double the morphine dose. Western countries [5, 6, 42]. Patients’ rights regarding treat- Previous studies on these factors are somewhat controver- ment decisions were incorporated into Finnish law in 1992, sial. Females have been shown to be less supportive towards and respecting the patient’swishesiscurrently oneofthe ending life without explicit request from the patient, but main principles in the ethical guidelines of the Finnish Med- also to be more supportive of alleviating pain and other ical Association [8, 9]. This social and cultural context to- symptoms regardless of the possible life-shortening effects gether with the shift from paternalism towards a more [22, 26]. In general, younger physicians accept PAS more patient-centred approach in clinical decision-making prob- often but are less willing to withdraw life-prolonging treat- ably influenced the responding physicians’ considerations on ments than older physicians [2, 22, 26]. The exact reasons the reprehensibility of hastened death and their willingness Piili et al. BMC Medical Ethics (2018) 19:40 Page 9 of 10 to comply with patients’ requests in the ethically complex Author details Faculty of Medicine and Life Sciences, University of Tampere, Tampere, situation in our study [6, 43]. Finland. Department of Oncology, Palliative Care Unit, Tampere University Hospital, Teiskontie 35, R-building, 33520 Tampere, Finland. Faculty of Social Strengths and limitations of the study Sciences, University of Tampere, Tampere, Finland. Rehabilitation Center Apila, Kangasala, Finland. Limitations of this study need to be acknowledged. 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BMC Medical EthicsSpringer Journals

Published: May 30, 2018

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