Continuing, Withdrawing, and Withholding Medical Treatment at the End of Life and Associated Characteristics: a Mortality Follow-back Study
Studies on forgoing treatment often ignore treatments that are continued until death.
To investigate how often specific treatments are withdrawn or withheld before death and to describe the associated patient, physician, and care characteristics.
National mortality follow-back study in Switzerland in 2013/2014 using a standardized survey to collect information on the patient’s end of life and demographics on the physician.
A random sample of adults who died non-suddenly without an external cause and who had met the physician completing the survey (N = 3051).
Any of nine specific treatments was continued until death, withdrawn, or withheld.
In 2242 cases (84%), at least one treatment was either continued until death or withheld or withdrawn. The most common treatment was artificial hydration, which was continued in 23%, withdrawn in 4%, and withheld in 22% of all cases. The other eight treatments were withdrawn or withheld in 70–94% of applicable cases. The impact of physician characteristics was limited, but artificial hydration, antibiotics, artificial nutrition, and ventilator therapy were more likely to be withheld at home and in nursing homes than in the hospitals.
Large differences exist between care settings in whether treatments are continued, withdrawn, or withheld, indicating the different availability of treatment options or different philosophies of care. While certain patient groups are more likely to have treatment withheld rather than attempted, neither patient nor physician characteristics impact the decision to continue or withdraw treatment.
KEY WORDSpalliative care end-of-life decisions withholding treatment medical decision-making
We thank the Swiss Federal Statistical Office for having sampled deaths for our study and the Swiss Academy of Medical Sciences (SAMS) for ensuring the anonymity of the questionnaires. We are indebted to the many physicians who participated in the study and filled in the questionnaires.
Further members of the Swiss Medical End-of-Life Decisions Study Group are as follows: Karin Faisst (St. Gallen), Felix Gutzwiller (Zurich), Samia Hurst (Geneva), Christoph Junker (Neuchâtel), Milo Alan Puhan (Zurich), Margareta Schmid (Zurich), and Sarah Ziegler (Zurich).
This study was funded by the Swiss National Science Foundation (grant 406740-139309, National Research Program 67 ‘End-of-Life’) and the Palliative Care Research funding program of the Swiss Academy of Medical Sciences; the Gottfried and Julia Bangerter-Rhyner Foundation; and the Stanley Thomas Johnson Foundation (grant PC 03/16).
Compliance with Ethical Standards
Consent from the patient was waived by the Zurich Cantonal Ethics Committee (KEK-StV No. 23/13).
Conflict of Interest
The authors declare that they do not have a conflict of interest.
- 14.Swiss Academy of Medical Sciences (SAMS). Management of dying and death. 2018. Available from: https://www.samw.ch/en/Ethics/Ethics-in-end-of-life-care/Guidelines-management-dying-death.html
- 15.Thomson S, Osborn R, Squires D, Reed SJ. International profiles of health care systems 2011: Australia, Canada, Denmark, England, France, Germany, Iceland, Italy, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. Commonwealth Fund pub. 1857Google Scholar
- 29.De Vleminck A, Pardon K, Beernaert K, Deschepper R, Houttekier D, Van Audenhove C, Deliens L, Vander Stichele R. Barriers to advance care planning in cancer, heart failure and dementia patients: a focus group study on general practitioners' views and experiences. PloS one. 2014;9(1):e84905.CrossRefGoogle Scholar