Introduction

Compared to other countries, an exceptionally high percentage of deaths in Switzerland is preceded by a decision to forgo life-prolonging treatments [1–3], contributing to a high overall prevalence of medical end-of-life decisions (MELDs). These differences between Switzerland and other countries may be explained by what Gysels et al. called "evidence for clearly distinguishable national cultures of end-of-life care, with differences in meaning, priorities, and expertise in each country" [4]. In addition to such cultural factors, previous research has also shown that certain groups of patients are more likely to experience death preceded by an MELD, particularly people who die of cancer and older people [5,6] and that there are differences in the type of MELD by patient’s sex and age [6–8]. Likewise, the involvement of patients or relatives in the decision-making process has been shown to be influenced by cultural and patient-related factors, such as age [8–10].

There are several ways in which also a physician’s characteristics could affect medical end-of-life decision-making and the discussion of these decisions with patients or relatives. However, a 2011 systematic review of the literature on patient and healthcare professional factors influencing end-of-life decision-making concluded that only a few studies examined the influence of physician-specific factors and those that did often focused on decision-making in hospital or acute care units only [11]. In Belgium MELDs were more frequent among physicians having received a postgraduate training in palliative or terminal care and among those having attended a non-Catholic university [6]. Younger physicians have also been reported to involve patients more often in discussions around MELDs [6,9]. Most studies, however, only assessed attitudes or evaluated hypothetical patients. In a U.S. study, Catholic physicians had significantly more objections to the withdrawal of life support than their Protestant peers [12] and in an international study, physicians with specific religious affiliations showed less willingness than non-religious physicians to administer drugs explicitly intending to hasten patient's death [13]. There is evidence that physician’s sex has an important impact on the time spent on communication [14] and on health outcomes [15]. Female physicians were reported to be less supportive than male physicians towards ending of life without explicit request, more supportive of intensified alleviation of pain and symptoms with possible life-shortening effect [16]. There is evidence that female physicians are more likely to engage in patient-centered communication [14], an important precondition for shared decision-making. Quite unsurprisingly, health outcomes also vary by physician's years of practice [17,18].

Cultural or country-specific factors could also influence the training and education of physicians. Depending on where a physician was trained, there may be not only variation regarding outcomes [17], but also whether a physician is more or less likely to make an MELD. Such cultural influence may also affect the likelihood of a physician involving patients and relatives in a discussion about MELDs. A study on end-of-life decision-making in an Israeli intensive care unit found that whether physicians had trained in America or in Eastern Europe had a large impact on how often they discussed forgoing life-sustaining treatments with patients [19]. Further evidence for the potential impact of physician’s characteristics on shared decision-making came from a systematic review that found that one of the biggest facilitators for shared-decision making was the motivation of health professionals and their view that shared-decision making would lead to better patient outcomes [20].

The lack of knowledge surrounding how physician’s characteristics impact real decision-making at the end of life–both the types of decision made as the involvement of others in this decision–makes it hard to address potential inequalities in decision-making, and to ensure shared decision-making is a priority in all end-of-life situations. With this study we aim to assess the impact of physician-related determinants of MELDs and patient involvement in these decisions. There are two specific research questions. First: Do physician characteristics have an impact on the likelihood of an MELD when controlling for both patient and setting characteristics? Second, do physician characteristics–in case an MELD took place–have an impact on the likelihood of patient and/or relatives being involved in shared decision-making when controlling for both the patient and setting characteristics?

Methods

Results

Medical end-of-life decisions

Out of 3,391 eligible deaths, 2,772 (83%) were preceded by forgoing a life-prolonging treatment (17% of cases), intensified alleviation of pain and symptoms (APS; 12%) or both measures combined (54%; Table 1).

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Table 1. Descriptives of the study population: Forgoing treatment(s)^* and APS^** in Switzerland 2013–2014 (N = 3,391).

https://doi.org/10.1371/journal.pone.0203960.t001

The estimated relative risk ratios (RRR) from a multinomial logistic regression model contrasting "forgoing alone", "APS alone" and "both measures combined" with "neither" as reference category are presented in Table 2, along with 95% confidence intervals. Patient's nationality and religion were dropped in the final model, because they did not contribute information.

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Table 2. Patient and physician related determinants for medical end-of-life decisions: multinomial logistic regression with neither forgoing nor APS (N = 619) as reference category adjusted for cause of death, place of death, language region and patients' age.

https://doi.org/10.1371/journal.pone.0203960.t002

Compared to physicians that graduated from a Swiss university, those who graduated from abroad reported substantially less often forgoing treatment alone (RRR: 0.30; 95% CI: 0.21–0.41) or combining forgoing treatment with APS (0.44; 0.34–0.55) while for APS alone there was only a marginal effect. Having graduated in 2000 or later had only an effect for the combination of forgoing and APS (1.60; 1.17–2.19), but not for the two "alone" categories. Forgoing life-prolonging treatment alone or combined with APS was less prevalent when physicians reported Catholic as their religious affiliation (0.71 / 0.72; 0.52–0.98 / 0.56–0.92), whereas among Protestant physicians the lower prevalence was predominantly driven by APS. The lowest prevalence however was found for the combination of forgoing and APS among physicians reporting another religious affiliation or philosophy of life (0.51; 0.37–0.71). Male physicians tended to report MELDs less frequently than their female colleagues. In all MELD categories, divorced patients substantially less often experienced an MELD (RRRs between 0.56 and 0.65).

It is tempting to line-up the impact of corresponding physician and patient determinants like sex, age, religious affiliation and foreign origin. The results of a multiple binary logistic regression model (adjusted additionally for the cause of death, place of death and language region) show that physician-related determinants had generally a larger effect size than patient-related ones (Fig 1). Compared to physicians that graduated from a Swiss university, those who graduated abroad reported significantly less often forgoing treatment or APS, whereas nationality of the patient was irrelevant. This contrast between a substantial effect among physicians but only minor effects among decedents also applied to religious affiliation. Only sex showed some similarity: Male patients and even more so patients cared for by a male physician were less likely to die following forgoing treatment or APS.

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Fig 1. Patient- vs. physician-related determinants for medical end-of-life decisions (forgoing treatment(s) and/or intensified alleviation of pain): Multiple logistic regression (N = 3,391).

Additionally adjusted for cause of death category, place of death and language region. Patient-related variables are mapped in bright green and physician-related variables in dark blue. Bars indicate 95% confidence intervals.

https://doi.org/10.1371/journal.pone.0203960.g001

Patient and family involvement in medical end-of-life decisions

Most MELDs (79%) were discussed with the patient directly or with their relatives (Table 3).

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Table 3. Descriptives of the study population: Discussion of forgoing treatment and/or APS with patient and/or relatives (N = 2,542).

https://doi.org/10.1371/journal.pone.0203960.t003

Involvement of the patient was more frequent among cancer patients than on average (53% vs. 37%). In multiple binary logistic regression analysis (not differentiating whether an MELD was discussed directly with the patient or only with relatives), however, there was no substantial variation between the broad cause of death groups. Nevertheless, the type of MELD had a large influence: Compared to forgoing a life-prolonging treatment alone, shared decision-making was substantially more frequent for combined forgoing and APS (OR: 1.51; 95% CI: 1.18–1.95) and much less frequent for APS alone (0.21; 0.15–0.29)(Table 4).

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Table 4. Involvement of patient and/or relative(s) in medical end-of-life decisions (MELD): Multiple logistic regression (N = 2,542).

https://doi.org/10.1371/journal.pone.0203960.t004

Discussing decisions with the patient or relatives was significantly more likely when physicians graduated more recently (in 1985–1999 / in 2000 or later: 1.34; 1.03–1.75 / 1.73; 1.27–2.37). Conversely, shared decision-making was significantly less likely when physicians graduated outside of Switzerland (0.65; 0.50–0.87) or when patients died elsewhere than in a hospital. Physician's sex and religion or philosophy had no influence on the frequency of discussing decisions with the patient or relatives and were dropped in the final model. Compared to married decedents, shared decision-making was less frequent when patients were single (0.32; 0.23–0.45) or divorced (0.41; 0.29–0.58), but not when they were widowed. Patient's sex, age, nationality and religious affiliation were irrelevant and were also dropped in the final model.

The other potential physician determinants (palliative care education, the importance of religion/life stance for making an MELD, number of deceased patients cared for) were tested but did not have a significant impact on either the likelihood of forgoing and/or APS or the involvement of patients and relatives in decision-making.

Discussion

Even when adjusting for patient and setting characteristics, physician's characteristics had a substantial impact on MELD practices and the prevalence of shared decision-making in our study population, suggesting a sizable potential for optimizing end-of-life care.

International medical graduates made substantially fewer MELDs than those who graduated from a Swiss university and when they made an MELD, they less often reported shared decision-making with the patient and/or their relatives. International medical graduates may be less familiar with shared decision-making and patient-centered care [25]. At the time of the survey, 29% of all physicians in Switzerland were international graduates, with almost 60% of them originating from Germany [26, 27]. A study revealed that German physicians chose more life-prolonging interventions than their Swedish peers [28] and a scoping review stated that "German physicians were found to be more likely to exclude patients, patients' families and non-medical staff from the decision-making process" [4]. In another study, it was shown that where physicians were trained had a significant impact on how often they discussed forgoing treatment with patients [19]. These findings support the notion that physicians’ medical education may have a long-lasting impact on their attitudes towards care and decision-making. Physicians who graduated more recently made more MELDs and discussed these more often with patients and relatives than their colleagues who graduated before 1985. Similarly, a Belgian study found in the late 1990s that MELDs were significantly less frequent among patients treated by GPs aged 55 years and older [29]. This may also be due to previously lacking education in ethics: In Switzerland the first compulsory ethics classes started in 1995 only [30]. Ethics education has been described as supporting physicians' confidence regarding procedural end-of-life issues [31] and as being associated with a higher likelihood of applying a written do not resuscitate order [32]. Physicians inclined to apply "full code" had less often read about end-of-life care and had less interest in discussing MELDs than physicians more disposed to withdrawing life-sustaining therapies [32]. However, a 2002 study showed that ethics education was not associated with confidence in decisions to withdraw life support after an intensive care unit rotation and argued instead for experiential, case-based, patient-centred curricula for physicians-in-training [33].

Moreover and independently of age and place of graduation, physicians' religion mattered: physicians with a religious affiliation made fewer MELDs than those without. This is in line with a former study in Switzerland exploring attitudes regarding hypothetical patients and where religious believers tended to disagree more often with end-of-life decisions than other doctors [34]. On an international level, evidence for an impact of religious belief on the general incidence of MELDs is rather weak and controversial [12]. There is more evidence, however, for non-religious physicians being more inclined to make MELDs that may result in the hastening of death [16,29,35,36], and for a larger impact of religion for more drastic life-shortening acts [13]. Of note, the importance attached to religion when making an MELD had no influence on real patterns in our study and did not support the expectations of intrinsic religiosity of physicians playing a major role [12,34]. In contrast to our expectations, physician's sex had an only marginal influence on MELD incidence and no impact at all regarding the prevalence of shared decision-making. Nevertheless, future research should not discount the possibility of an effect of gender.

Except for the cause of death, civil status was the only patient characteristic with an impact on MELD prevalence. Fairly in line with other studies [6], MELDs were significantly less frequent among divorced patients. In Switzerland, this group accumulated more hospital days in their last year of life than other unmarried people, even when adjusting for the burden of disease and other sociodemographics [37], suggesting suboptimal health care provision. Discussion of MELDs was less frequent for divorced patients, too, as well as for single patients, however not for widowed patients. This is remarkable, since there is evidence that, irrespective of civil status, up to 95% of people had someone they would trust to make medical decisions for them [38]. However, strong social support and formal proxy decision-makers may be rarer among single and divorced patients, leading to fewer opportunities for communication with physicians.

Place of death had a substantial impact on patient involvement, with shared-decision making being more frequent in hospitals than in nursing homes or at home. This differs from the findings of an international study [39], which found that discussion with patients in most countries was more frequent at home than in institutions.

Unsurprisingly, MELD category had a substantial impact on the prevalence of shared decision-making, with more than 80% involvement of patient/relatives when forgoing and APS are combined. In contrast, in the majority of cases of APS alone, physicians included neither patient nor relatives in the decision-making process, although they perceived their decision as a potentially life-shortening act.

Conclusions

The generally high prevalence of MELDs and shared decision-making in Switzerland support the notion that important goals like doctors' timely anticipation of end-of-life and departure from paternalistic medicine are largely accomplished. While there were few differences between patient groups in terms of MELDs or shared decision-making, divorced patients may be disadvantaged in the decision-making process and subsequent MELDs. Physicians should be proactive about engaging single and divorced patients in shared decision-making, possibly by identifying a proxy well in advance. The association between several physician's attributes and MELD practice points to the possibility of inequity in care and a substantial potential for improvement. The findings that older physicians and those graduated from abroad did not only make fewer MELDs but also if they made an MELD, they discussed it less often with patients, strongly call for additional efforts in residency training programs and physicians' vocational education in order to improve communication skills [42], preferably tailored to address local needs and context [43]. Communication has been called 'the cornerstone of good end-of-life care' [44]. An emphasis should also be given to strengthening physicians' motivation [16] and increasing awareness among patients and relatives that death is near [45], both being important elements in the process of improving end-of-life care.

Supporting information

Acknowledgments

We thank the Swiss Federal Statistical Office for having sampled deaths for our study and the Swiss Academy of Medical Sciences for ensuring anonymity of questionnaires for the identification of certifying physicians. We are indebted to the many physicians who participated in the study and filled in the questionnaires.

The members of the Swiss Medical End-of-Life Decisions Study Group are Milo Alan Puhan (Chairman), Matthias Bopp, Georg Bosshard (all Zürich), Karin Faisst (St. Gallen), Felix Gutzwiller (Zürich), Samia Hurst (Geneva), Christoph Junker (Neuchâtel), Margareta Schmid, Ueli Zellweger and Sarah Ziegler (all Zürich).