Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Original article

Vol. 150 No. 0102 (2020)

Medical end-of-life decisions in the oldest old in Switzerland

  • Kathrin Hug
  • Yolanda W.H. Penders
  • Heike A. Bischoff-Ferrari
  • Matthias Bopp
  • Georg Bosshard
  • for the Swiss End-of-Life Decisions Study Group
DOI
https://doi.org/10.4414/smw.2020.20177
Cite this as:
Swiss Med Wkly. 2020;150:w20177
Published
15.01.2020

Summary

AIMS OF THE STUDY

To analyse medical end-of-life decision making among the oldest old (80+ years) in Switzerland, focusing not only on treatments withheld or withdrawn but also on those continued until death.

METHODS

This was a retrospective follow-up study of deaths registered in Switzerland between August 2013 and January 2014 using a standardised questionnaire completed by the attending physician. All individuals aged 65 years and older who did not die suddenly and completely unexpectedly, and who had met the responding physician prior to death were included (n = 2842). We examined three age groups: 65–79, 80–89, and 90+ years. Logistic regression analysis was used to identify age-related differences, controlled for place of death and sociodemographic characteristics.

RESULTS

In 83.8% of the study population at least one medical end-of-life decision was made, and for 39.4% the use of a potentially life-sustaining treatment was documented. Alleviation of pain and other symptoms with a possible life-shortening effect was performed with 29% higher odds among the 90+-year-olds (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.01–1.66) than in the youngest age group. Withholding or withdrawing potentially life-sustaining treatment with or without the explicit intention to hasten death did not differ with age. However, when the frequency of withholding a potentially life-sustaining treatment was compared with the frequency of using this treatment (either continued until death or withdrawn later on), the former was more common in old age (80–89 years), and particularly in very old age (90+ years) for most of the treatments studied. This applied especially for ventilator therapy (80–89 years: OR 2.83, 95% CI 1.82–4.41; 90+ years: OR 6.17, 95% CI 2.89–13.17, compared with 65–79 years), artificial nutrition (ORs 2.33, 95% CI 1.46–3.71 and 4.44, 95% CI 2.28–8.65, respectively), and antibiotics (ORs 1.53, 95% CI 1.11–2.09 and 1.57, 95% CI 1.05–2.35, respectively). Age had no independent impact on artificial hydration.

CONCLUSIONS

The use of some potentially life-sustaining treatments decreased with older age and, in relation, the relative frequency of withholding such treatments increased. There may be various reasons for this finding: less benefit of a particular treatment in older patients for instance due to comorbidities, higher burden of treatment, and finally a tacit consensus of physicians and patients that death is nearing.

References

  1. Bundesamt für Statistik. Todesfälle. 2018 [last accessed 2019 Aug 2]. Available from: https://www.bfs.admin.ch/bfs/de/home/statistiken/bevoelkerung/geburten-todesfaelle/todesfaelle.html.
  2. Rietjens JA, Deschepper R, Pasman R, Deliens L. Medical end-of-life decisions: does its use differ in vulnerable patient groups? A systematic review and meta-analysis. Soc Sci Med. 2012;74(8):1282–7. doi:.https://doi.org/10.1016/j.socscimed.2011.12.046
  3. De Gendt C, Bilsen J, Mortier F, Vander Stichele R, Deliens L. End-of-life decision-making and terminal sedation among very old patients. Gerontology. 2009;55(1):99–105. doi:.https://doi.org/10.1159/000163445
  4. De Gendt C, Bilsen J, Van Den Noortgate N, Lambert M, Stichele RV, Deliens L. Prevalence of patients with do-not-resuscitate status on acute geriatric wards in Flanders, Belgium. J Gerontol A Biol Sci Med Sci. 2007;62(4):395–400. doi:.https://doi.org/10.1093/gerona/62.4.395
  5. Lloyd-Williams M, Kennedy V, Sixsmith A, Sixsmith J. The end of life: a qualitative study of the perceptions of people over the age of 80 on issues surrounding death and dying. J Pain Symptom Manage. 2007;34(1):60–6. doi:.https://doi.org/10.1016/j.jpainsymman.2006.09.028
  6. Lloyd A, Kendall M, Carduff E, Cavers D, Kimbell B, Murray SA. Why do older people get less palliative care than younger people? Eur J Palliat Care. 2016;23(3):132–7.
  7. Bosshard G, Zellweger U, Bopp M, Schmid M, Hurst SA, Puhan MA, et al. Medical end-of-life practices in Switzerland: A comparison of 2001 and 2013. JAMA Intern Med. 2016;176(4):555–6. doi:.https://doi.org/10.1001/jamainternmed.2015.7676
  8. van der Heide A, Deliens L, Faisst K, Nilstun T, Norup M, Paci E, et al.; EURELD consortium. End-of-life decision-making in six European countries: descriptive study. Lancet. 2003;362(9381):345–50. doi:.https://doi.org/10.1016/S0140-6736(03)14019-6
  9. Martins Pereira S, Pasman HR, van der Heide A, van Delden JJ, Onwuteaka-Philipsen BD. Old age and forgoing treatment: a nationwide mortality follow-back study in the Netherlands. J Med Ethics. 2015;41(9):766–70. doi:.https://doi.org/10.1136/medethics-2014-102367
  10. Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, et al.; Ethicus Study Group. End-of-life practices in European intensive care units: the Ethicus Study. JAMA. 2003;290(6):790–7. doi:.https://doi.org/10.1001/jama.290.6.790
  11. Levin PD, Sprung CL. Withdrawing and withholding life-sustaining therapies are not the same. Crit Care. 2005;9(3):230–2. doi:.https://doi.org/10.1186/cc3487
  12. Howard DS, Pawlik TM. Withdrawing medically futile treatment. J Oncol Pract. 2009;5(4):193–5. doi:.https://doi.org/10.1200/JOP.0948501
  13. Teixeira C, Ribeiro O, Fonseca AM, Carvalho AS. Ethical decision making in intensive care units: a burnout risk factor? Results from a multicentre study conducted with physicians and nurses. J Med Ethics. 2014;40(2):97–103. doi:.https://doi.org/10.1136/medethics-2012-100619
  14. Hurst SA, Perrier A, Pegoraro R, Reiter-Theil S, Forde R, Slowther AM, et al. Ethical difficulties in clinical practice: experiences of European doctors. J Med Ethics. 2007;33(1):51–7. doi:.https://doi.org/10.1136/jme.2005.014266
  15. Chambaere K, Rietjens JA, Smets T, Bilsen J, Deschepper R, Pasman HR, et al. Age-based disparities in end-of-life decisions in Belgium: a population-based death certificate survey. BMC Public Health. 2012;12(1):447. doi:.https://doi.org/10.1186/1471-2458-12-447
  16. van der Maas PJ, Van Delden JJ, Pijnenborg L, Looman CW. Euthanasia and other medical decisions concerning the end of life. Lancet. 1991;338(8768):669–74. doi:.https://doi.org/10.1016/0140-6736(91)91241-L
  17. Deliens L, Mortier F, Bilsen J, Cosyns M, Vander Stichele R, Vanoverloop J, et al. End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey. Lancet. 2000;356(9244):1806–11. doi:.https://doi.org/10.1016/S0140-6736(00)03233-5
  18. van der Maas PJ, van der Wal G, Haverkate I, de Graaff CL, Kester JG, Onwuteaka-Philipsen BD, et al. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med. 1996;335(22):1699–705. doi:.https://doi.org/10.1056/NEJM199611283352227
  19. Groenewoud JH, van der Heide A, Kester JG, de Graaff CL, van der Wal G, van der Maas PJ. A nationwide study of decisions to forego life-prolonging treatment in Dutch medical practice. Arch Intern Med. 2000;160(3):357–63. doi:.https://doi.org/10.1001/archinte.160.3.357
  20. Pijnenborg L, van der Maas PJ, Kardaun JW, Glerum JJ, van Delden JJ, Looman CW. Withdrawal or withholding of treatment at the end of life. Results of a nationwide study. Arch Intern Med. 1995;155(3):286–92. doi:.https://doi.org/10.1001/archinte.1995.00430030080009
  21. Bosshard G, Nilstun T, Bilsen J, Norup M, Miccinesi G, van Delden JJ, et al.; European End-of-Life Consortium. Forgoing treatment at the end of life in 6 European countries. Arch Intern Med. 2005;165(4):401–7. doi:.https://doi.org/10.1001/archinte.165.4.401
  22. Seale C. Hastening death in end-of-life care: a survey of doctors. Soc Sci Med. 2009;69(11):1659–66. doi:.https://doi.org/10.1016/j.socscimed.2009.09.025
  23. Schmid M, Zellweger U, Bosshard G, Bopp M, Swiss M ; Swiss Medical End-Of-Life Decisions Study Group. Medical end-of-life decisions in Switzerland 2001 and 2013: Who is involved and how does the decision-making capacity of the patient impact? Swiss Med Wkly. 2016;146:w14307. doi:.https://doi.org/10.4414/smw.2016.14307
  24. Penders YWH, Bopp M, Zellweger U, Bosshard G ; Swiss Medical End-of-Life Decisions Study Group. Continuing, Withdrawing, and Withholding Medical Treatment at the End of Life and Associated Characteristics: a Mortality Follow-back Study. J Gen Intern Med. 2019. doi:.https://doi.org/10.1007/s11606-019-05344-5
  25. Hurst SA, Zellweger U, Bosshard G, Bopp M ; Swiss Medical End-of-Life Decisions Study Group. Medical end-of-life practices in Swiss cultural regions: a death certificate study. BMC Med. 2018;16(1):54. doi:.https://doi.org/10.1186/s12916-018-1043-5
  26. Biola H, Sloane PD, Williams CS, Daaleman TP, Zimmerman S. Preferences versus practice: life-sustaining treatments in last months of life in long-term care. J Am Med Dir Assoc. 2010;11(1):42–51. doi:.https://doi.org/10.1016/j.jamda.2009.07.005
  27. Buiting HM, Rietjens JA, Onwuteaka-Philipsen BD, van der Maas PJ, van Delden JJ, van der Heide A. A comparison of physicians’ end-of-life decision making for non-western migrants and Dutch natives in the Netherlands. Eur J Public Health. 2008;18(6):681–7. doi:.https://doi.org/10.1093/eurpub/ckn084
  28. Bosshard G, Faisst K, Fischer S, Minder R, Zellweger U, Tschopp A, et al. Begrenzung lebenserhaltender Massnahmen bei Patienten am Lebensende in der deutschsprachigen Schweiz -- Resultate einer Todesfallstudie [Forgoing life-sustaining measures in patients at the end of life in the German-speaking part of Switzerland: results of a death certificate study]. Dtsch Med Wochenschr. 2005;130(50):2887–92. doi:.https://doi.org/10.1055/s-2005-923321
  29. Hamel MB, Lynn J, Teno JM, Covinsky KE, Wu AW, Galanos A, et al. Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT. J Am Geriatr Soc. 2000;48(S1, Suppl):S176–82. doi:.https://doi.org/10.1111/j.1532-5415.2000.tb03129.x
  30. Onwuteaka-Philipsen BD, Pasman HR, Kruit A, van der Heide A, Ribbe MW, van der Wal G. Withholding or withdrawing artificial administration of food and fluids in nursing-home patients. Age Ageing. 2001;30(6):459–65. doi:.https://doi.org/10.1093/ageing/30.6.459
  31. Raijmakers NJ, van Zuylen L, Costantini M, Caraceni A, Clark J, Lundquist G, et al.; OPCARE9. Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Ann Oncol. 2011;22(7):1478–86. doi:.https://doi.org/10.1093/annonc/mdq620
  32. Buiting HM, van Delden JJ, Rietjens JA, Onwuteaka-Philipsen BD, Bilsen J, Fischer S, et al.; EURELD-Consortium. Forgoing artificial nutrition or hydration in patients nearing death in six European countries. J Pain Symptom Manage. 2007;34(3):305–14. doi:.https://doi.org/10.1016/j.jpainsymman.2006.12.006
  33. Bükki J, Unterpaul T, Nübling G, Jox RJ, Lorenzl S. Decision making at the end of life--cancer patients’ and their caregivers’ views on artificial nutrition and hydration. Support Care Cancer. 2014;22(12):3287–99. doi:.https://doi.org/10.1007/s00520-014-2337-6
  34. Morita T, Shima Y, Adachi I ; Japan Palliative Oncology Study Group. Attitudes of Japanese physicians toward terminal dehydration: a nationwide survey. J Clin Oncol. 2002;20(24):4699–704. doi:.https://doi.org/10.1200/JCO.2003.10.155
  35. Welie JV, Ten Have HA. The ethics of forgoing life-sustaining treatment: theoretical considerations and clinical decision making. Multidiscip Respir Med. 2014;9(1):14. doi:.https://doi.org/10.1186/2049-6958-9-14
  36. van der Heide A, Onwuteaka-Philipsen BD, Rurup ML, Buiting HM, van Delden JJ, Hanssen-de Wolf JE, et al. End-of-life practices in the Netherlands under the Euthanasia Act. N Engl J Med. 2007;356(19):1957–65. doi:.https://doi.org/10.1056/NEJMsa071143
  37. Seale C. End-of-life decisions in the UK: a response to van der Heide and colleagues. Palliat Med. 2009;23(6):567–8. doi:.https://doi.org/10.1177/0269216309106500
  38. van der Heide A, Onwuteaka-Philipsen B, Deliens L, van Delden JJ, van der Maas PJ. End-of-life decisions in the United Kingdom. Palliat Med. 2009;23(6):565–6, author reply 567–8. doi:.https://doi.org/10.1177/0269216309106457
  39. Höfling W. Integritätsschutz und Patientenautonomie am Lebensende [Integrity and autonomy at the end of life]. Dtsch Med Wochenschr. 2005;130(14):898–900. doi:.https://doi.org/10.1055/s-2005-865105
  40. Spittler JF. Flüssigkeitsverzicht. Ethische Massstabsfindung in der gesellschaftlichen Kontroverse [Dehydration. Ethical standards finding in the social controversy]. Dtsch Med Wochenschr. 2005;130(4):171–4. doi:.https://doi.org/10.1055/s-2005-837391
  41. van Oorschot B, Lipp V, Tietze A, Nickel N, Simon A. Einstellungen zur Sterbehilfe und zu Patientenverfügungen -- Ergebnisse einer Befragung von 727 Arzten [Attitudes on euthanasia and medical advance directives]. Dtsch Med Wochenschr. 2005;130(6):261–5. doi:.https://doi.org/10.1055/s-2005-837410
  42. Weber M, Schildmann J, Schüz J, Herrmann E, Vollmann J, Rittner C. Ethische Entscheidungen am Lebensende--Kenntnisstand und Einstellungen Medizinstudierender [Ethical decision-making at the end of life - knowledge and attitudes of medical students]. Dtsch Med Wochenschr. 2004;129(28-29):1556–60. doi:.https://doi.org/10.1055/s-2004-828989
  43. Onwuteaka-Philipsen BD, Muller MT, van der Wal G, van Eijk JTM, Ribbe MW. Active voluntary euthanasia or physician-assisted suicide? J Am Geriatr Soc. 1997;45(10):1208–13. doi:.https://doi.org/10.1111/j.1532-5415.1997.tb03771.x
  44. Fischer S, Miccinesi G, Hornung R, Bosshard G, Deliens L, van der Heide A, et al., EURELD consortium. Responders and non-responders in a study on medical end-of-life decisions in Denmark, the Netherlands, Sweden and Switzerland. Soz Praventivmed. 2006;51(1):24–33. doi:.https://doi.org/10.1007/s00038-005-0004-x
  45. Bopp M, Penders YWH, Hurst SA, Bosshard G, Puhan MA ; Swiss End-of-Life Decisions Study Group. Physician-related determinants of medical end-of-life decisions - A mortality follow-back study in Switzerland. PLoS One. 2018;13(9):e0203960. doi:.https://doi.org/10.1371/journal.pone.0203960

Most read articles by the same author(s)

1 2 > >>