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GP Survey explores end of life decisions – Expert reaction

Posted in Science Alert: Experts Respond on July 24th, 2015.

A new survey of New Zealand GPs shows that many make decisions about end of life care that may indirectly or directly hasten death.

Caring for a patient at the end of their life is an unenviable challenge faced by many general practitioners. A new survey by researchers at the University of Auckland has canvassed GPs about the medical decisions undertaken in these situations. The research is published in the New Zealand Medical Journal.

GPs were asked specifically about the last death at which they were the attending doctor. Of the 650 respondents, 359 GPs (65.6 per cent) reported that they had made treatment decisions, such as withdrawing treatment or alleviating pain, taking into account the probability that they may hasten death.

Some of these GPs made explicit decisions about hastening death. Of the 359 GPs who reported making end-of-life medical decisions:

  • 16.2 per cent withheld treatments with the explicit purpose of not prolonging life or hastening the end of life.
  • 4.5 per cent (a total of 16 GPs) reported prescribing, supplying or administering a drug with the explicit purpose of hastening the end of life. The authors note this would be generally understood as euthanasia, although the survey did not use that term. In 15 of these cases, nurses gave the drug to the patient.

The authors compared their findings to an earlier survey undertaken in 2000, and found that the results were relatively similar, although more GPs reported having discussions with patients about end-of-life care in the current study.

The authors conclude: “Our study shows that medical decisions at the end-of-life that hasten death through the prescribing, supplying or administration of a drug with that explicit purpose, continue to be a reality in New Zealand, that nurses are allegedly involved in such practices, and there appears to be more discussion with patients about medical-decision making at the end-of-life.”

The Science Media Centre collected the following expert commentary from New Zealand researchers.

Prof Glynn Owens, Professor of Psychology, University of Auckland, comments:

“This is an important paper.  It is important for many reasons but notably, this is not because it says much that is different from what has been said before.  Rather it is important because of the similarity between what it says, and what preceded it.  Despite a gap of over a decade, a different response rate and (mostly) different authors, the study shows strikingly similar findings to those of the “2000” group when the issue of taking action explicitly to hasten death is considered.  Despite changes in medical practice, medical technology and the training and experience of practitioners  the issue of assisted dying refuses to go away.

“It is important to note that the prevalence figures noted here reflect percentages of deaths falling into different categories.  It would be a serious mistake to conclude from the observation that only 4.5% of the deaths considered involved assisted dying, that therefore 95.5% of practitioners never involve themselves in such practices.  The data reflect deaths, not practitioners. The participants were asked only about the last death with which they had dealt; it is not unreasonable to assume that there were practitioners out there whose most recent patient death had been uneventful but for whom a patient death preceding that one had involved some degree of assistance in dying.

“What these results, like other results from around the world show is that making assisted dying illegal does not, by waving some magic wand, miraculously stop it from happening.  Rather it simply means that the practice continues without any clear regulation, guidelines and, importantly, support for the practitioners involved.

“The fact that practitioners are willing to risk their careers and their liberty by acting illegally reflects the severity of the perceived need in those cases where it occurs.

“Modern times have seen a number of legislatures come to grips with this problem in their own particular ways; in the United States, Oregon pioneered (quickly to be followed by others) the regulation of physician assistance to patients who wished to decide when their lives would end.  Holland, after a period of ‘tolerated illegality’, in which assisted dying was illegal but (subject to constraints) practitioners were granted immunity from prosecution, now has rules in place which provide clear guidelines on when such assistance is acceptable.  In Canada, the judiciary have determined that citizens have a constitutional right to some form of assistance.

“Here in New Zealand, the recent case of Lecretia Seales, and earlier cases such as those of Joy Martin and Pat Davison have highlighted the need for this matter to be addressed with urgency.  We have come a long way from the notion of medical paternalism, and now accept the concept of autonomy as fundamental in the field of medical ethics.

“We cannot continue to ignore the issue of assisted dying; rather we need extensive and open discussion, accepting the need for compromise that will lead not just to respect for our patients’ right to lead their own lives, but also respect for their right to decide when and how they should end.”

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