title: A Survey of Physicians' Attitudes toward Decision-Making Authority for Initiating and Withdrawing VA-ECMO: Results and Ethical Implications for Shared Decision Making.
abstract: Although patients exercise greater autonomy than in the past, and shared decision making is promoted as the preferred model for doctor-patient engagement, tensions still exist in clinical practice about the primary locus of decision-making authority for complex, scarce, and resource-intensive medical therapies: patients and their surrogates, or physicians. We assessed physicians' attitudes toward decisional authority for adult venoarterial extracorporeal membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus.
  
  
  
  A survey of resident/fellow physicians and internal medicine attendings at an academic medical center, May to August 2013.
  
  
  
  We used a 24-item, internet-based survey assessing physician-respondents' demographic characteristics, knowledge, and attitudes regarding decisional authority for adult VA-ECMO. Qualitative narratives were also collected.
  
  
  
  A total of 179 physicians completed the survey (15 percent response rate); 48 percent attendings and 52 percent residents/fellows. Only 32 percent of the respondents indicated that a surrogate's consent should be required to discontinue VA-ECMO; 56 percent felt that physicians should have the right to discontinue VA-ECMO over a surrogate's objection. Those who self-reported as "knowledgeable" about VA-ECMO, compared to those who did not, more frequently replied that there should not be presumed consent for VA-ECMO (47.6 percent versus 33.3 percent, p = 0.007), that physicians should have the right to discontinue VA-ECMO over a surrogate's objection (76.2 percent versus 50 percent, p = 0.02) and that, given its cost, the use of VA-ECMO should be restricted (81.0 percent versus 54.4 percent, p = 0.005).
  
  
  
  Surveyed physicians, especially those who self-reported as knowledgeable about VA-ECMO and/or were specialists in pulmonary/critical care, favored a medical locus of decisional authority for VA-ECMO. VA-ECMO is complex, and the data may (1) reflect physicians' hesitance to cede authority to presumably less knowledgeable patients and surrogates, (2) stem from a stewardship of resources perspective, and/or (3) point to practical efforts to avoid futility and utility disputes. Whether these results indicate a more widespread reversion to paternalism or a more circumscribed usurping of decisional authority occasioned by VA-ECMO necessitates further study.
authors.affiliation: Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, New York, New York 10021 USA. Elc9076@med.cornell.edu.
authors.forename: Ellen C
authors.initials: EC
authors.lastname: Meltzer
authors.affiliation: Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, New York, New York 10021 USA.
authors.forename: Natalia S
authors.initials: NS
authors.lastname: Ivascu
authors.affiliation: Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, New York, New York 10021 USA.
authors.forename: Meredith
authors.initials: M
authors.lastname: Stark
authors.affiliation: 35 Glen Ridge Rd., Norwich, Vermont 05055 USA.
authors.forename: Alexander V
authors.initials: AV
authors.lastname: Orfanos
authors.affiliation: Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, New York, New York 10021 USA.
authors.forename: Cathleen A
authors.initials: CA
authors.lastname: Acres
authors.affiliation: Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, New York, New York 10021 USA.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Christos
authors.affiliation: John Snow, Inc., 44 Farnsworth St., Boston, Massachusetts 02210 USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Mangione
authors.affiliation: Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, New York, New York 10021 USA.
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Fins
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003657:Decision Making; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006801:Humans; D008297:Male; D010820:Physicians; D019727:Proxy; D011795:Surveys and Questionnaires; D028761:Withholding Treatment / Q000941:ethics*