Influence of physicians' life-stance on attitudes towards end-of-life decisions and actual end-of-life decision-making in six countries

Aim: To examine how physicians’ life stances affect their attitudes to end-of-life decisions and their actual end-of-life decision-making. Methods: Practising physicians from various specialties involved in the care of dying patients in Belgium, Denmark, The Netherlands, Sweden, Switzerland and Australia received structured questionnaires on end-of-life care, which included questions about their life stance. Response rates ranged from 53% in Australia to 68% in Denmark. General attitudes, intended behaviour with respect to two hypothetical patients, and actual behaviour were compared between all large life-stance groups in each country. Results: Only small differences in life stance were found in all countries in general attitudes and intended and actual behaviour with regard to various end-of-life decisions. However, with regard to the administration of drugs explicitly intended to hasten the patient’s death (PAD), physicians with specific religious affiliations had significantly less accepting attitudes, and less willingness to perform it, than non-religious physicians. They had also actually performed PAD less often. However, in most countries, both Catholics (up to 15.7% in The Netherlands) and Protestants (up to 20.4% in The Netherlands) reported ever having made such a decision. Discussion: The results suggest that religious teachings influence to some extent end-of-life decision-making, but are certainly not blankly accepted by physicians, especially when dealing with real patients and circumstances. Physicians seem to embrace religious belief in a non-imperative way, allowing adaptation to particular situations. Physicians’ attitudes to life and death appear to orient their end-of-life decision-making.1 It is important therefore to both assess their attitudes2 and understand exactly how these are related to end-of-life decision-making. Research has generally corroborated that (stronger) theistic religious beliefs are associated with lower acceptance of various end-of-life decisions (ELDs), particularly euthanasia.3–9 Often this is explained by the traditional viewpoints of Judaism, Catholicism, Protestantism and Islam (or their religious authorities) regarding end-of-life issues, extensively described in the bioethical literature.10–18 However, as these traditional religious doctrines are commonly balanced by considerations of due care and general sentiments of humanity and compassion, which come into play in actually dealing with patients, there is some dispute over the decisiveness of statements of doctrine for physicians’ actual decision-making.19 A specific research question of this study is therefore: are viewpoints from different life stances on different kinds of ELDs, as illustrated in the recent Lancet series,11 16 18 also translated into attitudes and actual practices of the physicians who adhere to these life stances? We will examine the effect of life stance on physicians’: * general attitudes to different ELDs: non-treatment decisions (NTDs); alleviation of pain and symptoms with a possible life-shortening effect; terminal sedation; and administration of lethal drugs (ie, physician-assisted dying (PAD)); * willingness to make these ELDs, given certain circumstances; * actual decision-making. We will also examine whether the country of residence has an effect, making it possible to evaluate also the influence of the surrounding (secular) culture.