title: End-of-life issues: Withdrawal and withholding of life-sustaining healthcare in the emergency department: A comparison between emergency physicians and emergency registrars: A sub-study.
abstract: OBJECTIVE
  We investigated and compared the importance of the considerations and discussions when withdrawing and withholding life-sustaining healthcare between emergency physicians (EP) and emergency registrars (ER).
  
  
  METHODS
  This was a sub-study of a prospective cross-sectional questionnaire-based case series conducted in six EDs. Primary outcomes were, which of the discussion and considerations, were rated most important by EP and ER in the decision-making process.
  
  
  RESULTS
  We studied responses relating to the care of 320 patients, of which 49.4% were women and the median age was 83 (interquartile range [IQR] 72-88). EP and ER were sole decision-makers in 185 (39.7%) and 135 (30.0%) of cases, respectively. Treatment was withdrawn or withheld in 72.0 and 90.6% of all deaths by EP and ER, respectively (P < 0.001). EP and ER provided full treatment in 88 (34%) and 19 (12.7%) of cases, respectively (P < 0.05). The consideration rated most important was prognosis: 165 (90.2%, confidence interval: 85.0-93.7) and 121 (90.3%, confidence interval: 84.1-94.2) for EP and ER, respectively. ER rated co-morbidities and age more important than did EP (P < 0.05). Both rated discussions with family as very important. EP and ER referred 6.0% versus 11.9% patients to palliative care services, respectively. The proportion of patients taking longer than 24 h to die was higher for ER compared with that for EP (14.1% vs 4.9%, P < 0.05).
  
  
  CONCLUSIONS
  We found that ER were more likely to withdraw/withhold life-sustaining healthcare, provide partial treatment, rate different considerations as important and their patients took longer to die than that of EP. Focused education and training might improve decision-making consistency between physicians and training registrars.
authors.affiliation: Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
authors.forename: Philip G
authors.initials: PG
authors.lastname: Richardson
authors.affiliation: Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
authors.forename: Jaimi
authors.initials: J
authors.lastname: Greenslade
authors.affiliation: Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
authors.forename: Jonathon
authors.initials: J
authors.lastname: Isoardi
authors.affiliation: Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: Davey
authors.affiliation: Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Gillett
authors.affiliation: Emergency Department, Royal Hobart Hospital, Hobart, Tasmania, Australia.
authors.forename: Alicia
authors.initials: A
authors.lastname: Tucker
authors.affiliation: Joseph Epstein Centre for Emergency Department Research, Western Health, Melbourne, Victoria, Australia.
authors.forename: Sharon
authors.initials: S
authors.lastname: Klim
authors.affiliation: Joseph Epstein Centre for Emergency Department Research, Western Health, Melbourne, Victoria, Australia.
authors.forename: Anne-Maree
authors.initials: AM
authors.lastname: Kelly
authors.affiliation: Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Abdelmahmoud
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D003430:Cross-Sectional Studies; D003657:Decision Making; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008020:Life Support Care; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D028761:Withholding Treatment / Q000706:statistics & numerical data*
keywords: death; emergency department; end-of-life care