title: Limiting treatment and shortening of life: data from a cross-sectional survey in Germany on frequencies, determinants and patients' involvement.
abstract: BACKGROUND
  Limiting treatment forms part of practice in many fields of medicine. There is a scarcity of robust data from Germany. Therefore, in this paper, we report results of a survey among German physicians with a focus on frequencies, aspects of decision making and determinants of limiting treatment with expected or intended shortening of life.
  
  
  METHODS
  Postal survey among a random sample of physicians working in the area of five German state chambers of physicians using a modified version of the questionnaire of the EURELD Consortium. Information requested referred to the patients who died most recently within the last 12 months. Logistic regression was performed to analyse associations between characteristics of physicians and patients regarding limitation of treatment with expected or intended shortening of life.
  
  
  RESULTS
  As reported elsewhere, 734 physicians responded (response rate 36.9%) and of these, 174 (43.2%) reported a withholding and 144 (35.7%) a withdrawal of treatment. Eighty one physicians estimated that there was at least some shortening of life as a consequence. In 25.9% of these cases hastening death had been discussed with the patient at the time or immediately prior to this action. Types of treatment most frequently limited was artificial nutrition (n = 35). Bivariate analysis indicates that limitation of treatment with possible or intended shortening of life for patients aged > 75 years is performed significantly more often (p = 0.007, OR 1.848). There was significantly less limitation of treatment in patients who died from cancer compared to patients with other causes of death (p = 0.01, OR 0.486). There was no significant statistical association with physicians' religion, palliative care qualification or frequencies of limiting treatment.
  
  
  CONCLUSIONS
  In comparison to recent research from other European countries, limitation of treatment with expected or intended shortening of life is frequently performed amongst the investigated sample. The role of clinical and non-medical aspects possibly relevant for physicians' decision about withholding or withdrawal of treatment with possible or intended shortening of life and reasons for non-involvement of patients should be explored in more detail by means of mixed method and interdisciplinary empirical-ethical analysis.
authors.affiliation: Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum, Markstraße 258a, 44799, Bochum, Germany. birte.dahmen@rub.de.
authors.forename: Birte Malena
authors.identifier: http://orcid.org/0000-0002-2303-0259
authors.initials: BM
authors.lastname: Dahmen
authors.affiliation: Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum, Markstraße 258a, 44799, Bochum, Germany.
authors.forename: Jochen
authors.initials: J
authors.lastname: Vollmann
authors.affiliation: Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum, Markstraße 258a, 44799, Bochum, Germany.|Diaconia University of Applied Sciences Bielefeld, Bethelweg 8, 33617, Bielefeld, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Nadolny
authors.affiliation: Institute for Ethics, Wilhelm Löhe University of Applied Science, Fürth, Germany.|Department of Medicine III, Klinikum der Universität München, Campus Großhadern, Munich, Germany.
authors.forename: Jan
authors.initials: J
authors.lastname: Schildmann
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D000066491:Clinical Decision-Making / Q000941:ethics; D003430:Cross-Sectional Studies; D004992:Ethics, Medical; D005260:Female; D005858:Germany; D006801:Humans; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D010358:Patient Participation; D010818:Practice Patterns, Physicians' / Q000941:ethics / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000941:ethics / Q000706:statistics & numerical data*; D028761:Withholding Treatment / Q000941:ethics / Q000706:statistics & numerical data
keywords: Cross-sectional study; End-of-life care; Limiting treatment; Medical ethics; Survey