Neonatal end-of-life decision making - Physicians' attitudes and relationship with self-reported practices in 10 European countries

Context The ethical issues surrounding end-of-life decision making for infa nts with adverse prognoses are controversial. Little empirical evidence is available on the attitudes and values that underlie such decisions in diffe rent countries and cultures. Objective To explore the variability of neonatal physicians' attitudes amon g 10 European countries and the relationship between such attitudes and sel f-reported practice of end-of-life decisions. Design and Setting Survey conducted during 1996-1997 in 10 European countri es (France, Germany, Italy, the Netherlands, Spain, Sweden, the United King dom, Estonia, Hungary, and Lithuania). Participants A total of 1391 physicians (response rate, 89%) regularly empl oyed in 142 neonatal intensive care units (NICUs). Main Outcome Measures Scores on an attitude scale, which measured views reg arding absolute value of life (score of 0) vs value of quality of life (sco re of 10); self-report of having ever set limits to intensive neonatal inte rventions in cases of poor neurological prognosis. Results Physicians more likely to agree with statements consistent with pre serving life at any cost were from Hungary (mean attitude scores, 5.2 [95% confidence interval {CI}, 4.9-5.5]), Estonia (4.9 [95% CI, 4.3-5.5]), Lithu ania (5.5 [95% CI, 4.8-6.1]), and Italy (5.7 [95% CI, 5.3-6.0]), while phys icians more likely to agree with the idea that quality of life must be take n into account were from the United Kingdom (attitude scores, 7.4 [95% CI, 7.1-7.7]), the Netherlands (7.3 [95% CI, 7.1-7.5]), and Sweden (6.8 [95% CI , 6.4-7.3]). Other factors associated with having a pro-quality-of-life vie w were being female, having had no children, being Protestant or having no religious background, considering religion as not important, and working in an NICU with a high number of very low-birth-weight newborns. Physicians w ith scores reflecting a more quality-of-life view were more likely to repor t that in their practice, they had set limits to intensive interventions in cases of poor neurological prognosis, with an adjusted odds ratio of 1.5 ( 95% CI, 1.3-1.7) per unit change in attitude score. Conclusions In our study, physicians' likelihood of reporting setting limit s to intensive neonatal interventions in cases of poor neurological prognos is is related to their attitudes. After adjusting for potential confounders , country remained the most important predictor of physicians' attitudes an d practices.