Decisions to limit care: evaluation of newly graduated physicians during a selection process for medical residency in Brazil

Introduction

'Doctor. Do whatever necessary to save her life'. This is a challenge for doctors in daily practice, mainly when it deals with attempts to prolong life and admission to the ICU should be denied. The objective of the present study is to determine attitudes and practices of newly graduated physicians in Brazil about end of life care and to evaluate the new set of skills they have to be prepared to deal with.

Methods

A multiple-choice cognitive test was applied to physicians as part of a selection process for a residency program. The question was about a 77-year-old woman, with dementia, who has lived in long-term geriatric care for the past 5 years. She was transferred to the hospital with acute respiratory failure and pneumonia. The lung image showed disseminated malignancy. The granddaughter (GD), although unaware of the prognosis, asked the doctor to do 'everything to save the life'. The candidates were asked for the appropriate behavior. Option (A) to treat, including performing advanced life support at the ICU, independent of a previous quarrel with the GD; Option (B) to not perform any diagnostic or therapeutically measure and inform the GD that this will no longer bring benefit to her grandmother; Option (C) to define, together with the GD, possible palliative interventions; or Option (D) to apply protocols based on evidence related to palliative care, independently of the GD's opinion. The correct answer was based on two skills: the concern about futile treatment and ethical issues – Option (C).

Results

A total of 1,133 physicians participated in the selection process for medical residency and answered the questionnaire. Of the respondents, 698 (61.61%) would rather define with the family possible palliative interventions (correct option – (C)); 312 respondents (27.54%) would treat the patient even without the family's opinion (option (A)); 122 respondents (10.77%) would apply protocols, again independent of the GD's opinion (option (D)); and one candidate (0.08%) chose option (B).

Conclusion

Although the concept of palliative care and the importance to share decisions with the family has been chosen by the majority of the newly graduating physicians, 38.31% would still make decisions independently of the family's opinion. Medical students have to be prepared for a new set of skills.