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What do emergency physicians think of law? Do they know the law? What role does it have in the practice of emergency medicine? Emergency physicians in New South Wales, Victoria and Queensland are being asked about these issues in a study by the Queensland University of Technology, Brisbane, Australia, titled ‘Withholding and withdrawing life-sustaining treatment from adults who lack capacity: The role of law in medical practice’. The study aims to examine the role that law plays in decisions to withhold or withdraw life-sustaining treatment from adults who lack capacity.

This interdisciplinary research project, funded by the Australian Research Council, will explore the legal knowledge of specialists who make end-of-life decisions, the extent to which legal issues are relevant to their clinical decision-making, and what legal education or training (if any) these specialists want. The final fieldwork stage of the project is a survey that is now being administered to seven specialties (including emergency medicine) that are likely to be involved in decisions to withhold or withdraw life-sustaining treatment from adults who lack capacity.

Does law at the end of life matter?

  1. Top of page
  2. Does law at the end of life matter?
  3. Improving law; improving legal understanding
  4. Emergency perspective is critical
  5. References

The above questions are important ones. Decisions to not provide or continue life-sustaining treatment are a common part of medical practice, particularly in settings such as the ED. We estimate that almost 40 000 adult deaths occur nationally each year following a medical decision to withhold or withdraw treatment.[1] When these decisions are made, doctors are not only performing their clinical role, they are also acting in significant medico-legal roles. For example, they may decide whether an adult lacks capacity, or guardianship legislation may grant them power to be a decision-maker or to supervise decisions made by others. Undertaking these roles can be challenging because of insufficient training, and because of complexity and ambiguity in the law.[1]

Despite the significance of these issues, they have been the subject of very little research. For example, there is only limited work – in the USA, Denmark and the UK – that purports to examine in a systematic way what doctors know of this area of law.[2-5] In Australia, no comprehensive empirical research has been conducted, although there have been studies into parts of the law that can be relevant to these decisions.[6-8] One was an exploratory study undertaken in the emergency setting by Wong, Weiland and Jelinek.[8] The authors surveyed members of the Australasian College for Emergency Medicine about their decisions and attitudes in relation to hypothetical scenarios involving advance directives and substitute decision-makers appointed by the patient. Significantly, this research revealed notable gaps in legal knowledge and training for emergency physicians, and called for further research in the area both in the emergency setting and beyond.

Improving law; improving legal understanding

  1. Top of page
  2. Does law at the end of life matter?
  3. Improving law; improving legal understanding
  4. Emergency perspective is critical
  5. References

The current research will make recommendations to improve the law, informed by clinical perspectives as to how the law is actually operating in practice. It will also identify the legal education or training needs (if any) of the specialists surveyed. We believe that improved law and legal understanding in this area will help doctors manage legal risk and reduce possible exposure to criminal, civil or disciplinary action. The personal, financial and professional cost of adverse engagement with the law is significant, so supporting doctors to navigate the relevant legal framework is important. We also believe that this research can help lead to better outcomes for patients and their families, as well as a more appropriate allocation of scarce health resources. Research suggests limited legal knowledge is linked to the practice of defensive medicine, and that fear of legal liability can lead to the provision of treatment that patients do not want.[2, 4]

Emergency perspective is critical

  1. Top of page
  2. Does law at the end of life matter?
  3. Improving law; improving legal understanding
  4. Emergency perspective is critical
  5. References

We conducted a pilot study from late 2011 to early 2012 to test the survey instrument. Overall, the results of that pilot were positive, including the level of interest in the topic of those who responded. However, of greatest concern to the research team was the limited engagement of emergency physicians: only 9% responded to the pilot study.

In July 2012, the questionnaire for the main study was posted to emergency physicians and the other six specialties who are commonly involved in decisions at the end of life. At the time this editorial is published, a final reminder, along with another copy of the questionnaire, will be sent to those who have not yet responded.

We invite you to participate (if you have not already) because the views of emergency physicians are particularly critical for our study. Decisions about whether to withhold or withdraw life-sustaining treatment are frequently made in the ED. But more importantly, the context in which emergency medicine is practised is quite different from other clinical settings. Emergency physicians will often have less time, information and opportunity for discussions with family and others than their colleagues in other specialties might have.[8] So it is critical that our findings – which include recommendations to improve the law and support doctors through training and education – are informed by the emergency medicine perspective. We appreciate those emergency physicians who have already responded to our survey and invite those who have not yet done so to consider supporting this research.

Competing interests

The questionnaire ‘Withholding and withdrawing life-sustaining treatment from adults who lack capacity: The role of law in medical practice’ was sent out to seven specialties (including emergency medicine) in mid July 2012. Reminders have been sent to those who have not yet responded to seek their assistance in completing the questionnaire. The survey will close soon at the end of August 2012, so we encourage you to share your views. Current and future research findings about the project are available here: http://www.qut.edu.au/research/research-projects/withholding-and-withdrawing-life-sustaining-medical-treatment

References

  1. Top of page
  2. Does law at the end of life matter?
  3. Improving law; improving legal understanding
  4. Emergency perspective is critical
  5. References
  • 1
    White B, Willmott L, Trowse P, Parker M, Cartwright C. The legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment: part 1 (New South Wales). J. Law Med. 2011; 18: 498522.
  • 2
    McCrary SV, Swanson JW, Perkins HS, Winslade WJ. Treatment decisions for terminally ill patients: physicians’ legal defensiveness and knowledge of medical law. Law Med. Health Care 1992; 20: 364376.
  • 3
    McCrary SV, Swanson JW. Physicians’ legal defensiveness and knowledge of medical law: comparing Denmark and the USA. Scand. J. Public Health 1999; 27: 1821.
  • 4
    McCrary SV, Swanson JW, Coulehan J, Faber-Langendoen K, Olick RS, Belling C. Physicians’ legal defensiveness in end-of-life treatment decisions: comparing attitudes and knowledge in states with different laws. J. Clin. Ethics 2006; 17: 1526.
  • 5
    Schildmann J, Doyal L, Cushing A, Vollmann J. Decisions at the end of life: an empirical study on the involvement, legal understanding and ethical views of preregistration house officers. J. Med. Ethics 2006; 32: 567570.
  • 6
    Darvall L, McMahon M, Piterman L. Medico-legal knowledge of general practitioners: disjunctions, errors and uncertainties. J. Law Med. 2001; 9: 167184.
  • 7
    Ashby M, Wakefield M, Beilby J. General practitioners’ knowledge and use of living wills. BMJ 1995; 310: 230.
  • 8
    Wong RE, Weiland TJ, Jelinek GA. Emergency clinicians’ attitudes and decisions in patient scenarios involving advance directives. Emerg. Med. J. 2011; doi: 10.1136/emermed-2011-200287.