Patient involvement in decisions to limit treatment: the crucial role of agreement between physician and patient.
OBJECTIVE
The aim of this study was to describe, first, the decision-making process concerning the limitation of life-prolonging treatment (DLT); second, the extent to which patients are actually involved in these decisions; and third, to detect medical and ethical factors that affect patient involvement.


METHODS
This prospective qualitative study enrolled 76 patients with incurable cancer with whom the limitation of life-prolonging treatment was discussed. Embedded researchers on the wards recorded the patient's history, medical condition, type of treatment limitation discussed, patient wishes, decision-making capacity, and patient involvement using an in-depth documentation procedure.


RESULTS
While the majority of patients were informed about their diagnosis, therapy, and course of disease (99%, 97%, 90%, respectively), only 47% were involved in DLT. Two thirds of the patients preferred palliative care, and one third wished to extend their lifetime. If patients preferred palliative care, they were more often in line with physicians' treatment goals than patients who were striving for longer survival (91.4% v 46.7%; P = .001). They also were involved significantly more often in DLT. Multivariate analysis showed that age, Karnofsky performance index or decision-making capacity had no impact on patient involvement.


CONCLUSIONS
Only half of the patients were involved in DLT. Surprisingly, the main predictor of patient involvement was not their medical condition, but agreement with physicians' palliative treatment goals. These results show that if physicians switch to comfort care in terminally ill patients and patients are not yet prepared to follow this line, treatment limitations are often decided without involving the patient.
Winkler
Eva C
EC
Department of Internal Medicine III, University Hospital Grosshadern, Ludwig-Maximilians University, 81377 Munich, Germany. eva.winkler@med.uni-muenchen.de
Reiter-Theil
Stella
S
Lange-Riess
Dorothee
D
Schmahl-Menges
Nina
N
Hiddemann
Wolfgang
W
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000628:therapy*; D010358:Patient Participation; D017060:Patient Satisfaction; D010817:Physician-Patient Relations; D011446:Prospective Studies; D013727:Terminal Care; D028761:Withholding Treatment