Abstract
BackgroundOutcome predictions in patients with acute severe neurologic disorders are difficult and influenced by multiple factors. Since the decision for and the extent of life-sustaining therapies are based on the estimated prognosis, it is vital to understand which factors influence such estimates. This study examined whether previous professional experience with rehabilitation medicine influences physician decision-making.MethodsA case vignette presenting a typical patient with an extensive brain stem infarction was developed and distributed online to clinical neurologists. Questions focused on prognosis, interpretation of an advanced directive, whether to withdraw life-sustaining treatments and information on prior rehabilitation experience from the survey respondent.ResultsOf the participating neurologists, 77% opted for the withdrawal of life-sustaining therapies (n = 70; response rate: 14.8%). This decision was not affected by age, gender, or length of clinical experience. Neurologists with experience in rehabilitation medicine tended to estimate a more positive prognosis than neurologists without, but this result was not significant (p = .13). There was an association between the intervention chosen and previous experience in rehabilitation; neurologists with experience in rehabilitation medicine opted significantly more often (31.8%) for continuing life-sustaining treatments than neurologists without such experience (8.7%, p = .04).ConclusionOur results indicate that there are subjective factors influencing decisions to limit life-sustaining treatments that are based on previous professional experience. This finding emphasizes the variability and cognitive bias of such decision processes and should be integrated into future guidelines for specialist training on end-of-life decision-making.
Highlights
With increasing therapeutic possibilities in intensive care, questions about prognostic evaluation, treatment goals, and decision-making on limiting life-sustaining treatments are becoming increasingly important and even more complex.In particular, disorders of consciousness and severe neurologic injuries, such as large brainstem stroke, challenge both caregivers and family members when deciding whether there is a chance of meaningful recovery, and based on that assessment, whether it would be in the patient’s interest to go through the act of withdrawing life support [1,2,3,4].There is a great variety of patient outcomes, as well as differences in patient’s psychological and emotional responses to these outcomes [5, 6]
Study Aims The aim of the present study was to investigate the influence of neurologists’ previous professional experience on decision pathways in end-of-life decision-making in stroke cases using a fictional vignette case
Neurologists’ Prognosis and Confidence in Their Estimate When asked how likely respondents considered the probability for the patient to regain consciousness and ability to communicate, the majority decided within the spectrum of unlikely
Summary
With increasing therapeutic possibilities in intensive care, questions about prognostic evaluation, treatment goals, and decision-making on limiting life-sustaining treatments are becoming increasingly important and even more complex.In particular, disorders of consciousness and severe neurologic injuries, such as large brainstem stroke, challenge both caregivers and family members when deciding whether there is a chance of meaningful recovery, and based on that assessment, whether it would be in the patient’s interest to go through the act of withdrawing life support [1,2,3,4].There is a great variety of patient outcomes, as well as differences in patient’s psychological and emotional responses to these outcomes [5, 6]. This study examined whether previous professional experience with rehabilitation medicine influences physician decision-making. Results: Of the participating neurologists, 77% opted for the withdrawal of life-sustaining therapies (n = 70; response rate: 14.8%). This decision was not affected by age, gender, or length of clinical experience. Conclusion: Our results indicate that there are subjective factors influencing decisions to limit life-sustaining treatments that are based on previous professional experience. This finding emphasizes the variability and cognitive bias of such decision processes and should be integrated into future guidelines for specialist training on end-of-life decision-making.
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