Opinion of Polish doctors on the use of futile therapy
Maria Damps, Maksymilian Gajda, Łukasz Wiktor, Elżbieta Byrska-Maciejasz, Beata Rybojad, Małgorzata Kowalska, Alicja Bartkowska-Śniatkowska, Anna Paprocka-Lipińska, Ewa Kucewicz-Czech
TL;DR
This study explores Polish doctors' views on discontinuing futile therapy, finding strong support for limiting it and identifying key barriers and facilitators.
Contribution
The study provides new insights into Polish physicians' attitudes and challenges regarding futile therapy discontinuation.
Findings
95% of Polish physicians support discontinuing futile therapy.
Fear of legal liability is the most common reason for undertaking futile therapy.
Clear legal guidelines and education are seen as key to facilitating decisions on limiting therapy.
Abstract
The discontinuation of futile therapy is increasingly discussed in Polish clinical practice. Given the need to ensure patient well-being, it is essential to consider whether all clinical options resulting from medical progress should be used for every patient and on what grounds decisions to limit therapy should be based. The aim of our study was to determine the opinions of Polish medical doctors on this topic. We anonymously surveyed physicians across various specialties. An analysis of the collected data was carried out using descriptive and analytical methods. A total of 323 physicians participated in the study; 93% of them were aware of the problem of futile therapy in adults, with intensivists being significantly more aware (P = 0.002). Additionally, 95% of respondents supported the idea of discontinuing futile therapy, and over 68% used the therapy discontinuation protocol. Among…
Genes, proteins, chemicals, diseases, species, mutations and cell lines named across the full text — each resolved to its canonical identifier and authoritative record.
| Overall | Intensivists | ||||
|---|---|---|---|---|---|
|
| No 140 (43.34%) | Yes 183 (56.66%) |
| ||
| Mode of interview | Offline | 131 (40.6%) | 53 (37.9%) | 78 (42.6%) | 0.688 |
| Online | 192 (59.4%) | 87 (62.1%) | 105 (57.4%) | ||
| Age (years) | Median [q25–q75] | 40.0 [33.0–51.0] | 37.0 [31.0–48.0] | 42.0 [35.0–53.0] |
|
| Missing | 2 (0.6%) | 1 (0.7%) | 1 (0.5%) | ||
| Sex | Female | 211 (65.3%) | 101 (72.1%) | 110 (60.1%) | 0.079 |
| Male | 112 (34.7%) | 39 (27.9%) | 73 (39.9%) | ||
| Length of employment (years) | Median [q25–q75] | 14.0 [7.00–25.0] | 12.0 [5.00–23.0] | 15.0 [8.50–26.0] | 0.052 |
| Work in the intensive care unit | Yes | 184 (58.4%) | 27 (19.9%) | 157 (87.7%) |
|
| No | 131 (41.6%) | 109 (80.1%) | 22 (12.3%) | ||
| Missing | 8 (2.5%) | 4 (2.9%) | 4 (2.2%) | ||
| Place of work—teaching hospital with ICU | Yes | 184 (57.0%) | 88 (62.9%) | 96 (52.5%) | 0.174 |
| No | 139 (43.0%) | 52 (37.1%) | 87 (47.5%) | ||
| Place of work—nonclinical ICU hospital | Yes | 184 (57.0%) | 88 (62.9%) | 96 (52.5%) | 0.174 |
| No | 139 (43.0%) | 52 (37.1%) | 87 (47.5%) | ||
| Place of work—hospital without ICU | Yes | 184 (57.0%) | 88 (62.9%) | 96 (52.5%) | 0.174 |
| No | 139 (43.0%) | 52 (37.1%) | 87 (47.5%) | ||
| Confession | Catholic who attends church every week | 129 (40.1%) | 65 (46.4%) | 64 (35.2%) | 0.173 |
| Catholic | 97 (30.1%) | 31 (22.1%) | 66 (36.3%) | ||
| Atheist | 67 (20.8%) | 33 (23.6%) | 34 (18.7%) | ||
| Protestant, Baptist | 29 (9.0%) | 11 (7.9%) | 18 (9.9%) | ||
| Missing | 1 (0.3%) | 0 (0%) | 1 (0.5%) | ||
| Overall | Intensivists |
| ||
|---|---|---|---|---|
| No 140 (43.34%) | Yes 183 (56.66%) | |||
| Contact with a dying patient | ||||
| Few cases in recent years | 42 (13.0%) | 37 (26.4%) | 5 (2.7%) |
|
| Several cases a year | 87 (26.9%) | 56 (40.0%) | 31 (16.9%) | |
| Several cases a month | 194 (60.1%) | 47 (33.6%) | 147 (80.3%) | |
| Witness to illness and death | ||||
| Yes | 238 (73.9%) | 90 (64.7%) | 148 (80.9%) |
|
| No | 84 (26.1%) | 49 (35.3%) | 35 (19.1%) | |
| Missing | 1 (0.3%) | 1 (0.7%) | 0 (0%) | |
| Knowledge of futile therapy in adults | ||||
| Yes | 297 (93.7%) | 121 (88.3%) | 176 (97.8%) |
|
| No | 20 (6.3%) | 16 (11.7%) | 4 (2.2%) | |
| Missing | 6 (1.9%) | 3 (2.1%) | 3 (1.6%) | |
| Knowledge of futile therapy in children | ||||
| Yes | 228 (71.3%) | 100 (71.9%) | 128 (70.7%) | 0.972 |
| No | 92 (28.8%) | 39 (28.1%) | 53 (29.3%) | |
| Missing | 3 (0.9%) | 1 (0.7%) | 2 (1.1%) | |
| Knowledge of guidelines for futile therapy | ||||
| Yes | 206 (64.4%) | 47 (33.8%) | 159 (87.8%) |
|
| No | 114 (35.6%) | 92 (66.2%) | 22 (12.2%) | |
| Missing | 3 (0.9%) | 1 (0.7%) | 2 (1.1%) | |
| Talk to patients and/or their family about discontinuing futile therapy | ||||
| Yes | 134 (41.5%) | 61 (43.6%) | 73 (39.9%) | 0.966 |
| No, even though it was necessary | 21 (6.5%) | 8 (5.7%) | 13 (7.1%) | |
| No, due to the type of specialization | 168 (52.0%) | 71 (50.7%) | 97 (53%) | |
| Prepared for discussing futile therapy discontinuation with the patient and/or the patient’s family | ||||
| Yes | 117 (41.5%) | 35 (30.7%) | 82 (48.8%) |
|
| No opinion | 80 (28.4%) | 44 (38.6%) | 36 (21.4%) | |
| No | 85 (30.1%) | 35 (30.7%) | 50 (29.8%) | |
| Missing | 41 (12.7%) | 26 (18.6%) | 15 (8.2%) | |
| Use of futile therapy is a mistake | ||||
| Yes | 187 (57.9%) | 76 (54.3%) | 111 (60.7%) | 0.103 |
| No opinion | 59 (18.3%) | 35 (25.0%) | 24 (13.1%) | |
| No | 77 (23.8%) | 29 (20.7%) | 48 (26.2%) | |
| Belief that discontinuing futile therapy is right | ||||
| Yes | 306 (94.7%) | 132 (94.3%) | 174 (95.1%) | 0.257 |
| No opinion | 10 (3.1%) | 7 (5.0%) | 3 (1.6%) | |
| No | 7 (2.2%) | 1 (0.7%) | 6 (3.3%) | |
| Belief that economic aspects should be decisive in discontinuation of futile therapy | ||||
| Yes | 130 (40.2%) | 55 (39.3%) | 75 (41.0%) | 0.957 |
| No opinion | 56 (17.3%) | 27 (19.3%) | 29 (15.8%) | |
| No | 137 (42.4%) | 58 (41.4%) | 79 (43.2%) | |
| What would make the decision to limit futile therapy easier? | ||||
| Unambiguous legal act | ||||
| Yes | 260 (81.3%) | 105 (75.0%) | 155 (86.1%) | 0.138 |
| Don’t know | 37 (11.6%) | 23 (16.4%) | 14 (7.8%) | |
| No | 23 (7.2%) | 12 (8.6%) | 11 (6.1%) | |
| Missing | 3 (0.9%) | 0 (0%) | 3 (1.6%) | |
| Precise eligibility criteria for limiting therapy | ||||
| Yes | 305 (95.3%) | 133 (96.4%) | 172 (94.5%) | 0.947 |
| Don’t know | 8 (2.5%) | 3 (2.2%) | 5 (2.7%) | |
| No | 7 (2.2%) | 2 (1.4%) | 5 (2.7%) | |
| Missing | 3 (0.9%) | 2 (1.4%) | 1 (0.5%) | |
| Education in this area (practical form of education, e.g. workshops) | ||||
| Yes | 307 (95.3%) | 130 (92.9%) | 177 (97.3%) | 0.25 |
| Don’t know | 8 (2.5%) | 4 (2.9%) | 4 (2.2%) | |
| No | 7 (2.2%) | 6 (4.3%) | 1 (0.5%) | |
| Missing | 1 (0.3%) | 0 (0%) | 1 (0.5%) | |
| Patient’s declaration of will/living will | ||||
| Yes | 279 (87.5%) | 119 (86.2%) | 160 (88.4%) | 0.333 |
| Don’t know | 25 (7.8%) | 15 (10.9%) | 10 (5.5%) | |
| No | 15 (4.7%) | 4 (2.9%) | 11 (6.1%) | |
| Missing | 4 (1.2%) | 2 (1.4%) | 2 (1.1%) | |
| Overall | Intensivists |
| ||
|---|---|---|---|---|
| No 140 (43.34%) | Yes 183 (56.66%) | |||
| Main reasons for undertaking/continuing futile therapy in adult patients: | ||||
| Fear of talking to the patient/patient’s family and their reaction | ||||
| Yes | 187 (57.9%) | 86 (61.4%) | 101 (55.2%) | 0.531 |
| No | 136 (42.1%) | 54 (38.6%) | 82 (44.8%) | |
| Fear of legal liability for withdrawing or withholding treatment | ||||
| Yes | 302 (93.5%) | 129 (92.1%) | 173 (94.5%) | 0.688 |
| No | 21 (6.5%) | 11 (7.9%) | 10 (5.5%) | |
| Heroic fight for life to the end, because this is the ethical duty of the doctor | ||||
| Yes | 82 (25.4%) | 50 (35.7%) | 32 (17.5%) |
|
| No | 241 (74.6%) | 90 (64.3%) | 151 (82.5%) | |
| Fear of being accused by the patient’s family of a lack of professional ethics | ||||
| Yes | 65 (20.1%) | 39 (27.9%) | 26 (14.2%) |
|
| No | 258 (79.9%) | 101 (72.1%) | 157 (85.8%) | |
| Fear of being accused by the patient’s family of the lack of professional ethics | ||||
| Yes | 201 (62.2%) | 97 (69.3%) | 104 (56.8%) | 0.073 |
| No | 122 (37.8%) | 43 (30.7%) | 79 (43.2%) | |
| Order/recommendation from the supervisor | ||||
| Yes | 126 (39.0%) | 49 (35.0%) | 77 (42.1%) | 0.434 |
| No | 197 (61.0%) | 91 (65.0%) | 106 (57.9%) | |
| Passivity in action (colloquial term—laziness) | ||||
| Yes | 81 (25.1%) | 22 (15.7%) | 59 (32.2%) |
|
| No | 242 (74.9%) | 118 (84.3%) | 124 (67.8%) | |
| Main reasons for undertaking/continuing futile therapy in newborns/children | ||||
| Fear of talking to the patient/patient’s parents (family) and their reaction | ||||
| Yes | 243 (75.2%) | 105 (75.0%) | 138 (75.4%) | 0.996 |
| No | 80 (24.8%) | 35 (25.0%) | 45 (24.6%) | |
| Fear of legal liability for withdrawing or withholding treatment | ||||
| Yes | 300 (92.9%) | 127 (90.7%) | 173 (94.5%) | 0.417 |
| No | 23 (7.1%) | 13 (9.3%) | 10 (5.5%) | |
| Heroic fight for life to the end, because this is the ethical duty of the doctor | ||||
| Yes | 171 (52.9%) | 88 (62.9%) | 83 (45.4%) |
|
| No | 152 (47.1%) | 52 (37.1%) | 100 (54.6%) | |
| Fear of being accused by colleagues of a lack of professional ethics | ||||
| Yes | 95 (29.4%) | 49 (35.0%) | 46 (25.1%) | 0.156 |
| No | 228 (70.6%) | 91 (65.0%) | 137 (74.9%) | |
| Fear of being accused by the patient’s family of a lack of professional ethics | ||||
| Yes | 218 (67.5%) | 108 (77.1%) | 110 (60.1%) |
|
| No | 105 (32.5%) | 32 (22.9%) | 73 (39.9%) | |
| Order/recommendation from the supervisor | ||||
| Yes | 138 (42.7%) | 55 (39.3%) | 83 (45.4%) | 0.55 |
| No | 185 (57.3%) | 85 (60.7%) | 100 (54.6%) | |
| Passivity in action (colloquial term—laziness) | ||||
| Yes | 65 (20.1%) | 22 (15.7%) | 43 (23.5%) | 0.224 |
| No | 258 (79.9%) | 118 (84.3%) | 140 (76.5%) | |
| Overall | Intensivists |
| ||
|---|---|---|---|---|
| No 140 (43.34%) | Yes 183 (56.66%) | |||
| Who should decide to discontinue futile therapy in adult patients? | ||||
| Patient in a declaration of will/living will | ||||
| Yes | 301 (94.1%) | 131 (94.9%) | 170 (93.4%) | 0.948 |
| Don’t know | 9 (2.8%) | 4 (2.9%) | 5 (2.7%) | |
| No | 10 (3.1%) | 3 (2.2%) | 7 (3.8%) | |
| Missing | 3 (0.9%) | 2 (1.4%) | 1 (0.5%) | |
| Doctors | ||||
| Yes | 314 (97.2%) | 133 (95.0%) | 181 (98.9%) | 0.343 |
| Don’t know | 4 (1.2%) | 3 (2.1%) | 1 (0.5%) | |
| No | 5 (1.5%) | 4 (2.9%) | 1 (0.5%) | |
| Nurses | ||||
| Yes | 43 (14.4%) | 14 (10.8%) | 29 (17.3%) | 0.239 |
| Don’t know | 68 (22.8%) | 37 (28.5%) | 31 (18.5%) | |
| No | 187 (62.8%) | 79 (60.8%) | 108 (64.3%) | |
| Missing | 25 (7.7%) | 10 (7.1%) | 15 (8.2%) | |
| Patient’s family | ||||
| Yes | 112 (36.6%) | 62 (45.9%) | 50 (29.2%) |
|
| Don’t know | 54 (17.6%) | 28 (20.7%) | 26 (15.2%) | |
| No | 140 (45.8%) | 45 (33.3%) | 95 (55.6%) | |
| Missing | 17 (5.3%) | 5 (3.6%) | 12 (6.6%) | |
| Court | ||||
| Yes | 118 (38.4%) | 60 (44.4%) | 58 (33.7%) | 0.389 |
| Don’t know | 70 (22.8%) | 30 (22.2%) | 40 (23.3%) | |
| No | 119 (38.8%) | 45 (33.3%) | 74 (43.0%) | |
| Missing | 16 (5.0%) | 5 (3.6%) | 11 (6.0%) | |
| Who should decide to discontinue futile therapy in pediatric patients? | ||||
| Doctors | ||||
| Yes | 309 (95.7%) | 132 (94.3%) | 177 (96.7%) | 0.469 |
| Don’t know | 6 (1.9%) | 2 (1.4%) | 4 (2.2%) | |
| No | 8 (2.5%) | 6 (4.3%) | 2 (1.1%) | |
| Head physician | ||||
| Yes | 200 (64.7%) | 79 (59.0%) | 121 (69.1%) | 0.474 |
| Don’t know | 41 (13.3%) | 20 (14.9%) | 21 (12.0%) | |
| No | 68 (22.0%) | 35 (26.1%) | 33 (18.9%) | |
| Missing | 14 (4.3%) | 6 (4.3%) | 8 (4.4%) | |
| Nurses | ||||
| Yes | 41 (13.8%) | 13 (10.0%) | 28 (16.8%) | 0.573 |
| Don’t know | 68 (22.9%) | 30 (23.1%) | 38 (22.8%) | |
| No | 188 (63.3%) | 87 (66.9%) | 101 (60.5%) | |
| Missing | 26 (8.0%) | 10 (7.1%) | 16 (8.7%) | |
| Child’s parents | ||||
| Yes | 204 (65.2%) | 95 (69.3%) | 109 (61.9%) | 0.253 |
| Don’t know | 35 (11.2%) | 18 (13.1%) | 17 (9.7%) | |
| No | 74 (23.6%) | 24 (17.5%) | 50 (28.4%) | |
| Missing | 10 (3.1%) | 3 (2.1%) | 7 (3.8%) | |
| Guardianship/court | ||||
| Yes | 146 (47.9%) | 72 (53.3%) | 74 (43.5%) | 0.503 |
| Don’t know | 63 (20.7%) | 27 (20.0%) | 36 (21.2%) | |
| No | 96 (31.5%) | 36 (26.7%) | 60 (35.3%) | |
| Missing | 18 (5.6%) | 5 (3.6%) | 13 (7.1%) | |
| Missing | 3 (0.9%) | 2 (1.4%) | 1 (0.5%) | |
| Who would decide to discontinue futile therapy in relation to the surveyed | ||||
| He or she | ||||
| Yes | 295 (93.1%) | 131 (94.9%) | 164 (91.6%) | 0.816 |
| Don’t know | 14 (4.4%) | 5 (3.6%) | 9 (5.0%) | |
| No | 8 (2.5%) | 2 (1.4%) | 6 (3.4%) | |
| Missing | 6 (1.9%) | 2 (1.4%) | 4 (2.2%) | |
| Doctors | ||||
| Yes | 294 (92.7%) | 126 (90.6%) | 168 (94.4%) | 0.64 |
| Don’t know | 7 (2.2%) | 5 (3.6%) | 2 (1.1%) | |
| No | 16 (5.0%) | 8 (5.8%) | 8 (4.5%) | |
| Missing | 6 (1.9%) | 1 (0.7%) | 5 (2.7%) | |
| Head physician | ||||
| Yes | 154 (50.7%) | 63 (47.4%) | 91 (53.2%) | 0.761 |
| Don’t know | 44 (14.5%) | 18 (13.5%) | 26 (15.2%) | |
| No | 106 (34.9%) | 52 (39.1%) | 54 (31.6%) | |
| Missing | 19 (5.9%) | 7 (5.0%) | 12 (6.6%) | |
| Nurses | ||||
| Yes | 35 (11.8%) | 11 (8.4%) | 24 (14.5%) | 0.565 |
| Don’t know | 41 (13.8%) | 17 (13.0%) | 24 (14.5%) | |
| No | 221 (74.4%) | 103 (78.6%) | 118 (71.1%) | |
| Missing | 26 (8.0%) | 9 (6.4%) | 17 (9.3%) | |
| Family | ||||
| Yes | 121 (39.7%) | 62 (45.9%) | 59 (34.7%) | 0.288 |
| Don’t know | 36 (11.8%) | 17 (12.6%) | 19 (11.2%) | |
| No | 148 (48.5%) | 56 (41.5%) | 92 (54.1%) | |
| Missing | 18 (5.6%) | 5 (3.6%) | 13 (7.1%) | |
| Court | ||||
| Yes | 69 (23.0%) | 36 (27.1%) | 33 (19.8%) | 0.689 |
| Don’t know | 56 (18.7%) | 23 (17.3%) | 33 (19.8%) | |
| No | 175 (58.3%) | 74 (55.6%) | 101 (60.5%) | |
| Missing | 23 (7.1%) | 7 (5.0%) | 16 (8.7%) | |
Peer Reviews
No public reviews on file for this paper yet. If you reviewed it on a platform where reviews are public (OpenReview, ICLR, NeurIPS, ICML), you can paste yours below so the community can read it here.
Videos
No videos yet. Explain this paper in a talk, walkthrough, or lecture? Add one.
Taxonomy
TopicsEthics and Legal Issues in Pediatric Healthcare · Palliative Care and End-of-Life Issues · Healthcare cost, quality, practices
Introduction
Polish research on therapeutic boundaries was initiated by experts in the fields of ethics, medicine, and law at a conference entitled “The limits of medical therapies” in 2008. The tangible result of this scientific meeting was the establishment of the Polish Working Group on End-of-Life Ethical Problems and the development of a definition of futile medical care [1]. Maintaining the functions of organs that do not bring any benefits to the patient and do not make it possible to achieve the assumed therapeutic goals is called futile therapy (FT). FT prolongs the dying process and is related to the suffering of patients and their families, and the violation of human dignity. This definition is similar to the term “low-value care”—unlikely to benefit patients and can even unintentionally harm them [2]. However, FT is a broader medical-ethical-legal concept. Limiting FT requires palliative treatment, ensuring the patient’s comfort and providing care, nutrition, and hydration. Based on this definition, recommendations and guidelines for making medical decisions regarding medically futile actions were developed. The first recommendations for discontinuing persistent life-sustaining treatment were published for pediatricians (2011) [3] followed by specialists in anesthesiology and intensive care of adults (2014) [4], neonatologists (2019) [5], and pediatric intensive care unit (PICU) specialists (2022) [6]. Based on the position of the appointed team of experts, the Patient Ombudsman issued a publication on the implementation of the patient’s right to a dignified death, containing standards for end-of-life medical therapies (2021) [7]. The latest Polish document extensively discussing end-of-life medical care is the Position of the Polish Society of Internal Medicine Working Group on Medical Futility at Internal Medicine Units [8].
Physicians providing care to critically and terminally ill patients have received useful tools to assist in making ethically significant decisions.
Considering the broadly understood well-being of patients, it is necessary to evaluate whether all clinical options resulting from medical progress should be applied to every patient and to establish criteria for deciding when to limit therapy. The SarsCoV-2 pandemic necessitated reconsideration of triage protocols and the distribution of resources, particularly funding [9].
The debate on the use/limitation of FT in our country is taking place behind the scenes. Apart from the above-mentioned guidelines and recommendations of scientific societies, we still do not know the real independent opinions of medical doctors, nurses, and society on this subject. Therefore, we decided to conduct a questionnaire survey among medical doctors, nurses, and students (as representatives of the society) to learn about the clinical practices and personal opinions of the respondents on the discussed topic. We believe, that the obtained results of the study help explain the perception of the mentioned problem, recognize its determinants as well as indicate possible solutions, and determine further procedures to improve the clinical and social situation. Therefore, a survey was designed to determine the opinions of physicians, nurses, and students. The results regarding the opinions of Polish nurses have already been analyzed and published [10]. In this study, we present the results of the survey conducted among physicians. Further research assessing public opinions on this topic is in progress. The purpose of our work was to understand the clinical practice and opinions of Polish medical doctors regarding the use of FT. We aimed to answer the significant question: How often is FT used, why is it used, and what can be done to change this practice?
Methods
In 2022, a cross-sectional study was conducted using a proprietary questionnaire (Supplementary Material). The Polish-language questionnaire consisted of two parts with a total of 26 questions. The first part consisted of eight questions focused on sociodemographic characteristics, such as sex, age, and religion, as well as professional information, including practice, workplace, and medical specialties. In Poland, anesthesiology and intensive care remain joint specialties—physicians in this field both administer anesthesia in operating rooms and manage intensive care units (ICUs), with no official separation between pediatric and adult specialists. The second part of the survey consisted of 18 questions focused on medical workers’ opinions on various aspects of FT, including the reasons for its implementation and the legitimacy of its limitations. The questionnaire was available in two forms, traditional paper and electronic, and contained both open-ended and closed questions (single- and multiple-choice). All respondents were asked to answer the questions on their own. Electronic access was secured by a professional license number and e-mail verification. The questions were prepared by the authors of the study after consultation with Polish experts in this field such as medical doctors with extensive experience in ICUs, specialists in palliative medicine, or representatives of the Polish Palliative Scientific Society. The questionnaire was validated in a group of 20 randomly selected medical workers, who completed the survey twice, 1 week apart. The percentage agreement of the answers between the test and retest was assessed, and Cohen’s kappa was calculated for the key questions. The obtained results indicated good or very good repeatability of the questions. Physicians of all specialties employed in hospitals located in the Silesian, Lesser Poland, Subcarpathian, and Greater Poland voivodeships were invited to participate in the study (500 subjects, representing approximately 4% of professionally active physicians in these regions). Participation was voluntary and anonymous; study participants did not incur additional costs or receive any compensation. The study design was approved by the Ethics Committee of the Medical University of Silesia (KNW/0022/KB/284/18). We confirm that all methods were performed in accordance with the relevant guidelines and regulations.
The received paper surveys were checked for completeness. The study included questionnaires with a full answer of eight questions focused on sociodemographic characteristics and at least 16 of the 18 questions of the second part. Eleven surveys out of 142 paper versions were rejected because of the lack of completed data. In the electronic version, the system required answers to all questions. Depending on the type of question, the answers to open-ended questions were grouped by the principal investigator and the author of the survey and matched to the simplified categories. We differentiated the answers between intensivists and non-intensivists due to the significant difference in practical experience regarding the discussed topic. We were curious whether the opinion of medical doctors not working in ICUs differed significantly from that of intensivists. Since the limitation of FT in children is very controversial, we wanted to check whether the subjects’ declaration varies on the type of patients, adults or children. Qualitative variables were characterized as numbers and percentages. The χ^2^ test of independence was used to determine whether there were significant relationships between pairs of nominal variables. As quantitative variables deviated from the normal distribution, the Shapiro–Wilk test was used and reported as the median with the interquartile range (IQR). For nonparametric tests, the Mann–Whitney U test was used to analyze differences between groups. In all analyses, the criterion of P < 0.05 was used to indicate statistical significance. All statistical analyses were performed using R software (version 4.1.0, R Foundation for Statistical Computing, Vienna, Austria).
Results
Characteristics of the study population
Among the 500 physicians who were invited to participate, 323 joined the study (64.6% participation rate). The paper version was completed by 131 respondents (40.6%) and the online version was completed by 192 participants (59.4%). The median age of the participants was 40 years (IQR 33–51), and intensivists were significantly older than other specialists (42 vs. 37 years, P = 0.017). The majority of the study participants were women (N = 211, 65.3%) and Catholics (70.2%); however, 57% of the respondents reported weekly participation in church services (see Table 1).
Work experience and workplace
The median work experience was 14 years (IQR 7–25 years), which did not differ between intensivists and other specialists. Among non-intensivists, 19.9% of participants had experience working in ICUs. Notably, most of the respondents were employed in university hospitals with ICUs (57%; see Table 1).
Experience and opinions related to futile therapy
Less than half (40%) of the respondents talked to patients’ families about the discontinuation of therapy, with no differences found between specialties. Additionally, 41.5% of respondents (N = 117) reported feeling prepared to have these conversations with their patients with intensivists feeling significantly more prepared than other specialties (82% vs. 35%, P = 0.01). However, 30% of participants did not consider themselves prepared for such a conversation, regardless of their specialty, and 6% of physicians avoided talking to patients’ families despite the need to do so. The majority of the respondents who reported having no experience talking to patients’ families about this topic did not work in a place where such a need existed. Additionally, one question on the survey addressed the frequency of possible contact with a dying patient. More than half of the respondents (60.1%) declared that such an opportunity occurred several times a month, with intensivists having the greatest opportunity for contact. Most of the respondents (93%) were familiar with the problem of FT in adults, with intensivists being significantly more aware of it (P = 0.002). Additionally, more than 73% of respondents had experience with FT in pediatric practice, with no significant differences between specialties. Over 87% of the surveyed intensivists knew the guidelines for discontinuing FT in adults, whereas only about half were aware of similar documentation for children. A total of 95% of respondents supported the idea of discontinuing FT, and over 68% of respondents had used the therapy discontinuation protocol (see Table 2).
Reasons for futile therapy
The main reason for the family’s refusal to limit FT was not accepting the inevitability of death (Table 3). Among the most common reasons for continuing FT in adult patients, respondents cited fears of legal liability for not taking such actions (93.5%), concerns about being accused of unethical behavior (62.2%), and fears of discussing the situation with the patient or their family and their reactions (57.9%). While non-intensivists were more likely to be afraid of the opinions of their colleagues, they also believed that one must fight heroically for life until the very end. The opinions of the respondents regarding working with pediatric patients were similar, but the fear of talking to parents and being accused of unethical behavior predominated. Nearly half of the respondents noted that the reason for using FT was the recommendation of the head of the department (see Table 3).
Limitations of futile therapy and related decisions
The majority of respondents (94.7%) believed that limiting FT was appropriate, but more than half (57.9%) considered the use of FT as a medical error.
One-fifth of the respondents had no opinion on this topic. Opinions on the impact of economic considerations on the use or discontinuation of FT were equally divided. Among the reasons for the lack of consent of the patient’s family to limit FT, the most common was a lack of acceptance of the inevitability of death (n = 255, 78.9%). Almost half of respondents (157, 48.6%) indicated this was related to patient’s family members’ belief in the supernatural possibilities of medicine. Almost 60% of the surveyed physicians believed that the family did not trust them enough, which was why they did not agree to discontinue therapy.
The respondents also reported on factors regarding making decisions about limiting FT. These included precise qualification criteria for limiting therapy and education in this area (95.3%), the patient’s declaration of will (87.5%), and a clear legal framework (81.3%; see Table 2).
A crucial goal was to identify the entity responsible for the discontinuation of FT. In the case of adult patients, respondents believed that the cessation of FT should be decided by the patient in a declaration of will (94.1%), followed by the physician (97.2%). Approximately one-third of respondents mentioned the patient’s family, except for intensivists, who reported the patient’s significantly less frequently than other specialties. In controversial cases, almost 40% of respondents indicated the court to be the entity responsible for making the decision to discontinue FT. In the case of FT among pediatric patients, 95.7% of the physicians indicated medical rationale as the reason for discontinuation. Decisions made by parents were indicated by 65.2% of the respondents as the reason for discontinuation, and approximately half of the respondents indicated the court. Notably, 92.9% of the physicians agreed to withdraw futile treatment if the patient suffered from an incurable disease. Most participants (93.1%) stated that the decision to discontinue FT should be made by the patient in a living will or a declaration of will. Over 90% of the respondents indicated the decision should be made by the physician and approximately 40% reported it should be determined by the family, with approximately a quarter of respondents indicating the decision should be made by the court (see Table 4).
Differences in the opinions of intensivists
The intensivists who participated in the study had greater knowledge of the discontinuation of FT, relevant recommendations, and guidelines as well as more practical experience in caring for dying patients. In addition, intensivists were much less likely to allow the patient’s family to make the decision to discontinue the patient’s therapy (P = 0.004). Intensivists were also less concerned about the opinions of other doctors and the patient’s family regarding the ethics of their behavior (P < 0.001 and P = 0.005, respectively). They did not feel a heroic obligation to provide futile treatment by fighting to the end (P = 0.007) and more frequently admitted to passivity in action, such as avoiding making decisions (P = 0.003). Additionally, intensivists considered the use of renal replacement therapy as a component of FT (P < 0.001), similar to pharmacological and mechanical support of the circulatory system (P = 0.03).
Discussion
This research shows that the issue of FT is widely known in the Polish medical community, and the majority of respondents consider its use to be medical malpractice. Similar results were obtained in a study conducted in Poland in 2011 by Kübler et al. [11]. Among physicians they assessed working in ICUs, 93% reported not undertaking certain therapeutic activities, and 75% refrained from other activities due to their futility. Although Polish law allows the discontinuation of therapy, the matter is still not regulated. For most of the surveyed doctors, a clear legal act, if introduced, would facilitate decision-making in coordination with the already published Guidelines and the Position of the Patient Ombudsman. In a study conducted in 2016 among Australian physicians, one-third of the respondents indicated fear of legal consequences as the reason for conducting FT [12]. The Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) [13], collected opinions from 178 hospitals in 31 countries and found that the individual factors that had the greatest impact on decision-making regarding end-of-life care were doctors’ beliefs, hospital policies, and regional conditions. However, in this study, approximately 80% of the physicians supported the idea of withholding and withdrawing therapeutic procedures due to their futility, regardless of an agreement with the patient's family.
On the other hand, Japanese ethicists leave the decision to the family and note the need for honest information from medical staff about the futility of therapy [14]. The difference in opinions highlights not only the role of the regional culture but also the fact that the discussion conducted in the humanist community may differ significantly from that in the medical community. Nevertheless, proper communication with the patient's family plays an important role in the process of avoiding FT [15–17]. Our respondents indicated that the primary reasons for continuing FT included fear of talking to a family that does not accept the inevitability of the patient’s death, lack of trust in the doctor, and concern about potential legal claims from the family. In our previous study regarding nurses' opinions on the discussed topic [10], 6% of participants believed that they were sufficiently prepared for such a conversation. This issue requires comprehensive education, workshops, and the development of soft skills, as indicated by over 90% of our survey participants. Simply believing in the validity of discontinuing therapy is not sufficient to improve the quality of end-of-life care.
A declaration of will, i.e. the willingness to decide for oneself, is the most popular proposed solution to controversial situations [18–21]. Respecting the patient’s will and self-determination regarding their treatment would, in the authors’ opinion, be an expression of respect for the patient’s right to make decisions. However, patients often lack influence over their end-of-life care. The concept of a living will also poses many practical problems. It is impossible to predict future and uncertain events. Therefore, in such cases, information about the nature, purpose, and effects of medical interventions may not be complete. Opponents of living wills also argue that perceptions of quality of life and the will to live can differ significantly between younger and older individuals. Moreover, a living will needs to be constantly updated. Another possible solution is to introduce a medical proxy [22, 23]. However, we did not ask about the institution of a medical proxy, which is a limitation of our study. To the best of our knowledge, there is poor knowledge on this subject in the Polish medical community, but we see a need to deepen and investigate this issue in future research.
Many of our respondents highlighted the particular difficulty of talking to the parents of pediatric patients. They also expressed feelings of ethical responsibility to ensure that medical decisions are made with the consensus of the child’s family. Most members of the American Academy of Pediatric Section of Critical Care did not support discontinuing therapy against the wishes of the patient’s parents, even if they agreed with the idea [24]. This reluctance may stem from the fear of potential lawsuits, which are common in the USA. Nonetheless, providing professional support to families during these difficult decisions should be a priority to avoid conflict. Potential conflicts between the therapeutic team and the patient’s family could be easily resolved if an objective mediator was involved in the communication process.
In our study, the majority of the respondents were intensivists who regularly make decisions about end-of-life care. In 2019, a survey conducted among Polish pulmonologists revealed that most respondents did not routinely talk to patients with advanced chronic obstructive pulmonary disease about end-of-life issues such as the need to make decisions about invasive mechanical ventilation, cardiopulmonary resuscitation, or the place of dying [25]. Similarly, it appears that Polish intensivists may not engage in these conversations as frequently as necessary, particularly in the ICU. However, our study suggests that intensivists are less influenced by the idealized vision of a miracle-working doctor and may find it easier to make decisions about discontinuing therapy. Regular contact with dying patients can help maintain some degree of autonomy from the emotional influences of the patient’s family or other specialties although it may also contribute to a type of burnout characterized by passivity, as our results prove.
Our research was limited by the representativeness of the study group for the entire medical community in Poland. The study group constituted less than 0.5% of all physicians in the country, and the selection of study participants was focused mainly on the southern voivodeships. The only criterion for inclusion was being a doctor. However, it is acknowledged that the issues of FT and the professional responsibility of doctors in the context of applicable legal acts in our country are important for fostering constructive discussions and developing actions that regulate the practice of such therapies and align with the expectations of both patients’ families and medical staff. Another limitation of our study is the absence of questions regarding opinions on the institution of a medical proxy, which warrants further research.
Conclusions
The majority of the physicians who participated in the study supported the idea of not practicing FT, and this issue is well known to Polish medical staff. However, the obtained results confirmed, that intensivists had better knowledge of the discontinuation of FT, as well as more practical experience in caring for dying patients and they did not feel a heroic obligation to provide futile treatment by fighting to the end. Simultaneously the intensivists more frequently admitted to passivity in action, such as avoiding making decisions. We concluded, that further education and improved communication with the patient’s family are needed. Additionally, improving society’s awareness of the importance and role of the declaration of will and a medical proxy as an opportunity to influence end-of-life therapy may contribute to improving medical practice in this area, including an acceptance of refraining from FT. Medical doctors who have practical experience in the care of dying patients can contribute most to achieving this goal and preventing low-value care.
Supplementary Material
ckae202_Supplementary_Data
The reference list from the paper itself. Each links out to its DOI / PubMed record.
- 1Bołoz W , Krajnik M et al The definition of overzealous therapy. The consensus of the Polish Working Group of the End-of-Life Ethics. Adv Palliat Med 2008;7:77–8.
- 2Bertijn Kool R , Verkerk EW, Meijs J et al Assessing volume and variation of low-value care practices in the Netherlands. Eur J Public Health 2020;30:236–40.31950995 10.1093/eurpub/ckz 245PMC 7183367 · doi ↗ · pubmed ↗
- 3Dangel T , Grenda R, Kaczkowski J et al Zaniechanie i wycofanie się z uporczywego leczenia podtrzymującego życie u dzieci. Wytyczne dla lekarzy. Polskie Towarzystwo Pediatryczne, Warszawa, 2011.
- 4Kubler A , Siewiera J, Durek G et al Guidelines regarding the ineffective maintenance of organ functions (futile therapy) in ICU patients incapable of giving informed statements of will. Anaesthesiol Intensive Ther 2014;46:229–34.10.5603/AIT.a 2014.003825293473 · doi ↗ · pubmed ↗
- 5Zalecenia Polskiego Towarzystwa Neonatologicznego. Standardy opieki medycznej nad noworodkiem w Polsce, 2019.
- 6Bartkowska-Śniatkowska A , Byrska-Maciejasz E, Cettler M et al Guidelines regarding ineffective maintenance of organ functions (futile therapy) in paediatric intensive care units. Anaesthesiol Intensive Ther 2021;53:369–75. 10.5114/ait.2021.11145135100794 PMC 10172958 · doi ↗ · pubmed ↗
- 7Stanowisko Zespołu powołanego przy Rzeczniku Praw Pacjenta ds. opracowania standardów postępowania w terapiach medycznych stosowanych w okresie kończącego się życia. Warszawa, 2021.
- 8Szczeklik W , Krajnik M, Pawlikowski J et al Zapobieganie terapii daremnej u dorosłych chorych umierających w szpitalu—stanowisko Grupy Roboczej Towarzystwa Internistów Polskich ds. Terapii Daremnej na Oddziałach Internistycznych. Część 1: chory umierający nieubezwłasnowolniony, niebędący w stanie podejmować świadomych decyzji co do leczenia w sytuacji daremności medycznej stosowanej terapii. Med. Prakt 2023;4:121–40.