Correspondence

Treatment for Life-Threatening Illness

N Engl J Med 1993; 329:736September 2, 1993

Article

To the Editor:

Do physicians, nurses, allied health professionals, and members of the general public systematically choose more aggressive treatment for patients they do not know and family members than they would want for themselves?

To answer this question, we prepared a questionnaire, which was completed by 90 doctors, 251 nurses and other health professionals, and 193 high-school students and members of the general public. Using a standard clinical scenario tested in other studies,1-3 we asked respondents to choose a treatment for an 82-year-old man with dementia who was described as having arrived in the emergency department with life-threatening gastrointestinal bleeding; no guidance was available from the patient, his family, or others. There were three sets of circumstances: in one the respondent was the patient, in the second the patient was a family member, and in the third the respondent was the emergency room physician treating a patient he or she did not know. The choices consisted of “palliative,” “limited,” “surgical,” or “intensive” treatment; cardiopulmonary resuscitation (CPR) or no CPR; and four feeding strategies, ranging from tube feeding to spoon feeding only.

Respondents chose more aggressive treatment for a person they did not know than for a family member and, in turn, more aggressive treatment for a family member than for themselves (chi²F = 84.00; df = 2; P<0.001 by Friedman's analysis of variance) (Table 1Table 1The Types of Treatment for Life-Threatening Illness Chosen by the Respondents When They Imagined That They Were the Patient, That a Family Member Was the Patient, and That They Were the Physician Treating a Patient They Did Not Know.). The same pattern was seen for feeding choices (chi²F = 58.48; df = 2; P<0.001) and CPR use (chi²Q = 139.32; df = 2; P<0.001 by Cochran's test). There was no significant difference in the degree of aggressiveness between the two groups of respondents.

This study has some limitations. A survey may not represent what people will actually do. In previous studies, however, the survey choices of elderly people4 closely approximated their actual choices when they completed advance directives5. The results are consistent with our previous observations that physicians3 and nurses,2 when presented with the same hypothetical case, said they would provide more extensive treatment than elderly persons and residents of a home for the aged said they would want for themselves under similar conditions4,5.

This is a relatively small, Canadian sample that was not randomized. Caution should be exercised in applying the results to other settings. We conclude that with respect to the treatment of incompetent older adults, people indicate they would do unto others as they would not want done unto themselves.

Peteris Darzins, B.M., B.S., F.R.A.C.P.
McMaster University

D. William Molloy, M.B., M.R.C.P.(I.), F.R.C.P.(C.)
McMaster Clinic, Hamilton Civic Hospitals

Christine Harrison, Ph.D.
McMaster University, Hamilton, ON L8V 1C3, Canada

5 References

1. 1

   Molloy DW, Guyatt GH, Alemayehu E, et al. Factors affecting physicians' decisions on caring for an incompetent elderly patient: an international study. Can Med Assoc J 1991;145:947-952
   Web of Science

2. 2

   Lever JA, Molloy DW, Eisemann M, et al. Variability in nurses' decisions about the care of chronically ill elderly patients: an international study. Humane Med 1992;8:138-144
   Medline

3. 3

   Alemayehu E, Molloy DW, Guyatt GH, et al. Variability in physicians' decisions on caring for chronically ill elderly patients: an international study. Can Med Assoc J 1991;144:1133-1138
   Web of Science

4. 4

   Molloy DW, Guyatt G, Alemayehu E, McIlroy W. Treatment preferences, attitudes toward advance directives and concerns about health care. Humane Med 1991;7:285-290
   Medline

5. 5

   Molloy DW, Urbanyi M, Horsman J, Guyatt GH, Bedard M. Two years experience with a comprehensive health care directive in a home for the aged. Ann R Coll Physicians Surg Can 1992;25:433-436
   Medline