After analyzing the decision-making process of Turkish physicians on medical futility at the end of life in the ICU, three primary themes emerged. These themes were illustrated in Fig. 1. The physicians stated that they do not make challenging end-of-life decisions alone, but as part of a team. However, the specifics of how this team-based decision-making process works remain unclear. There are differing practices and opinions on whether nurses or other healthcare personnel should be involved in these processes. While participants mentioned that consultations are routinely conducted with relevant departments, these consultations are often perceived as procedures to complete patient files or to provide legal protection. Legal influence emerged as the most influential factor in decision-making processes, consistently emphasized by all participants. “Legal pressure” is an umbrella term that encompasses both the challenges arising from legal obligations and uncertainties due to gaps in legislation and physicians’ biases and fears of litigation. Addressing this issue requires legal reforms, providing physicians with psychological support, and increasing their legal awareness. This theme was mentioned 122 times, making it the most frequently coded theme.
“A 40-year-old terminal patient presents with complaint and upon examination, a tumor is detected. The surgeon assesses it and says that it is an advanced stage with metastasis, and surgery is not an option. (…) The patient goes to the oncologist, and he/she may or may not give treatment, indicating that this patient will not benefit from oncological treatment. Then the patient gets worse at home, comes to the emergency room, and is admitted to intensive care. (…) Now, the surgeon has done nothing, the oncologist has done nothing, too. But as an intensive care physician in Türkiye, I cannot say that nothing can be done to this patient, I am not taking him/her. Neither the patient’s relatives nor other doctors are ready for this, and even most doctors do not accept it either.” (D9).
Categories Found in Interviews Regarding Decisions on Futile Treatment at the End of Life in Intensive Care. (Numbers in parentheses indicate the coding frequency for each category in the interview transcripts.)
Physicians may face various legal influence depending on the case. They may feel obligated to follow legal regulations, or they may be uncertain about how to establish advance directives for end-of-life care due to a lack of legal guidance. Sometimes, physicians may practice defensive medicine to protect themselves legally. They may document their practices differently in patient files, such as recording CPR for a patient even if CPR was not performed if they believe it would be deemed futile. Besides legal pressure, physicians may struggle with social pressure and economic conflicts of interest. Social pressure can come from colleagues and patients’ relatives. Decisions may be influenced by supervisors due to the hierarchical structure of the medical profession. Additionally, well-known figures or influential individuals might exert influence to ensure their relatives receive improved or more specialized care.
Physicians’ decision-making processes in the context of futility
Regarding futility at the end of life, physicians have three critical ‘points of no return’ in their decision-making processes. Figure 2 illustrates these points and the measures that can prevent their occurrence. The figure highlights that the insufficient number of palliative care centers is the most crucial factor, and exceeding these critical points depends on individual preferences. Figure 3 details the intricate process of a patient’s hospitalization, starting from the emergency department and ending in ICU admission. This delineation underscores the direct impact of physicians’ ethical awareness in the context of futility and the preferences expressed by the patients’ families on the decision to admit a patient to the ICU.
The critical points of no return in physicians’ decision-making processes in the context of futility
Process of decision-making around ICU admission of patients in the context of futility
Factors in decision-making in the context of futility
The decision-making process at the end of life in the context of futility involves various factors such as the patient’s city of residence, the physician’s ethical awareness regarding futility, and the characteristics and preferences of both patients and their relatives. The geographical location of the patient plays a significant role, as the number of private hospitals and the presence of an operational palliative center in the city affect the decision-making process. Physicians note that they are compelled to admit patients to intensive care when there are no alternative options due to a lack of sufficient palliative centers. They also claim that patients with futile treatment prospects may more readily secure a bed in the ICU of private hospitals. These parameters vary between metropolises and small cities, with larger cities, especially Istanbul, facing more significant organizational challenges.
Physicians’ ethical awareness is crucial in informing patients and their relatives about futility. While some medical professionals advocate for allocating all available resources to every patient without considering futility, there is often resistance to referrals from palliative care to intensive care. Patients are initially categorized based on their medical conditions. Patients receiving futile treatment in the ICU are classified into three categories: those at the end of life, long-term care patients, and victims of medical malpractice. In this context, having an adequate number of not only palliative care centers but also nursing homes and hospices is crucial. It is noteworthy that there are currently no hospices in Türkiye. Only one participant mentioned that maximal treatment was provided due to considerations of medical malpractice without concern of futility.
Building trust between the medical team and patients/relatives is crucial. However, the trust established by the patient or their relatives within the professional community plays a significant role. For instance, if a patient or their relative is a health worker, especially a physician, the medical team is more likely to accept their request not to be intubated during ICU admission. This is because the status of a patient (or their relative) as a health worker helps establish a level of trust within the professional community. Physicians have pointed out that there are no legal regulations on advance directives in Türkiye. Therefore, they decline requests made by patients not to be intubated. However, they emphasize that if the patient or their family members sign a refusal of treatment form and choose to return home, there will be no legal complications. Unfortunately, the legal regulations for a hospitalized patient to provide advance directives are not clearly defined. Consequently, many hospitalized patients, even those receiving futile treatment, continue to receive care. Physicians fear potential legal repercussions for not providing care to a patient without a clear medical indication. As a result, the right to withhold care from a patient lacking a medical indication is often not exercised.
Normative concepts affecting decision-making in the context of futility
In our study, we identified several normative concepts that influence physicians’ decision-making processes at the end of life. These concepts include benefit, patient age, justice, and conscience. The term “benefit” is commonly used in the context of “medical benefit.” However, upon analyzing the meaning attributed to the concept of benefit, we found that a detailed exploration was lacking. Evaluation primarily occurred with regards to the success of treatment.
Physicians noted that age has a significant impact on decision-making, with a focus on old age often being interpreted in relation to comorbidity. Physicians stated that elderly individuals, even in good health, are less likely to respond positively to treatment compared to younger patients. The concept of chronological age, therefore, functions as a criterion with physiological impacts rather than possessing direct and absolute influence. That is, age is considered a hypothetical criterion that necessitates evaluation based on medical consequences and ethical implications. [26] The absence of guidelines on the interpretation of old age or the classification of comorbidity raises concerns about potential discrimination against the elderly.
In relation to the concept of justice, participants highlighted the wastage of resources due to futile treatment, making fair allocation challenging. Although physicians expressed motivation to assess resources in decision-making processes and allocate them fairly, they emphasized that the primary responsibility in this regard lies with politicians and directors. Physicians underscored the importance of making decisions in accordance with legal regulations and health policies, emphasizing that fair distribution is primarily guided by these regulations.
Conscience is a normative concept that plays a significant and crucial role in the decision-making process for physicians considering end-of-life treatment choices. Unlike other normative concepts, physicians consider conscience as the most important strategy for resolving ethical conflicts during end-of-life care. They may be motivated by religious beliefs or seek to avoid future regrets while making these decisions. The concept of deciding conscientiously is essential for physicians while making difficult decisions during end-of-life care.
“If you turn off the inotrope or significantly reduce the oxygen support for a terminal patient, then at that moment, probably their heart will stop. They will probably pass away very shortly. [pause] This, you know, is something that is left to the conscience of that individual doctor; in my view, it is a bit like killing. If I were in that situation and someone were to cut off my support, I would certainly not take offense, feel hurt; I wouldn’t do anything of that sort. But it is different when you do it to someone else.” (D6).
Conscientiousness is unquestionably a virtue that health professionals should have [27]. However, some individuals believe that making decisions based on conscience is sufficient to resolve ethical dilemmas. As a result, they do not feel the need to use any guiding principles or frameworks when making end-of-life decisions.
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