PMID- 28001135
OWN - NLM
STAT- MEDLINE
DCOM- 20180315
LR  - 20220408
IS  - 1046-7890 (Print)
IS  - 1945-5879 (Electronic)
IS  - 1046-7890 (Linking)
VI  - 27
IP  - 4
DP  - 2016 Winter
TI  - A Survey of Physicians' Attitudes toward Decision-Making Authority for Initiating 
      and Withdrawing VA-ECMO: Results and Ethical Implications for Shared Decision 
      Making.
PG  - 281-289
LID - 2016274281 [pii]
AB  - OBJECTIVE: Although patients exercise greater autonomy than in the past, and 
      shared decision making is promoted as the preferred model for doctor-patient 
      engagement, tensions still exist in clinical practice about the primary locus of 
      decision-making authority for complex, scarce, and resource-intensive medical 
      therapies: patients and their surrogates, or physicians. We assessed physicians' 
      attitudes toward decisional authority for adult venoarterial extracorporeal 
      membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus. 
      DESIGN, SETTING, PARTICIPANTS: A survey of resident/fellow physicians and 
      internal medicine attendings at an academic medical center, May to August 2013. 
      MEASUREMENTS: We used a 24-item, internet-based survey assessing 
      physician-respondents' demographic characteristics, knowledge, and attitudes 
      regarding decisional authority for adult VA-ECMO. Qualitative narratives were 
      also collected. MAIN RESULTS: A total of 179 physicians completed the survey (15 
      percent response rate); 48 percent attendings and 52 percent residents/fellows. 
      Only 32 percent of the respondents indicated that a surrogate's consent should be 
      required to discontinue VA-ECMO; 56 percent felt that physicians should have the 
      right to discontinue VA-ECMO over a surrogate's objection. Those who 
      self-reported as "knowledgeable" about VA-ECMO, compared to those who did not, 
      more frequently replied that there should not be presumed consent for VA-ECMO 
      (47.6 percent versus 33.3 percent, p = 0.007), that physicians should have the 
      right to discontinue VA-ECMO over a surrogate's objection (76.2 percent versus 50 
      percent, p = 0.02) and that, given its cost, the use of VA-ECMO should be 
      restricted (81.0 percent versus 54.4 percent, p = 0.005). CONCLUSIONS: Surveyed 
      physicians, especially those who self-reported as knowledgeable about VA-ECMO 
      and/or were specialists in pulmonary/critical care, favored a medical locus of 
      decisional authority for VA-ECMO. VA-ECMO is complex, and the data may (1) 
      reflect physicians' hesitance to cede authority to presumably less knowledgeable 
      patients and surrogates, (2) stem from a stewardship of resources perspective, 
      and/or (3) point to practical efforts to avoid futility and utility disputes. 
      Whether these results indicate a more widespread reversion to paternalism or a 
      more circumscribed usurping of decisional authority occasioned by VA-ECMO 
      necessitates further study.
CI  - Copyright 2016 The Journal of Clinical Ethics. All rights reserved.
FAU - Meltzer, Ellen C
AU  - Meltzer EC
AD  - Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, 
      New York, New York 10021 USA. Elc9076@med.cornell.edu.
FAU - Ivascu, Natalia S
AU  - Ivascu NS
AD  - Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, 
      New York, New York 10021 USA.
FAU - Stark, Meredith
AU  - Stark M
AD  - Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, 
      New York, New York 10021 USA.
FAU - Orfanos, Alexander V
AU  - Orfanos AV
AD  - 35 Glen Ridge Rd., Norwich, Vermont 05055 USA.
FAU - Acres, Cathleen A
AU  - Acres CA
AD  - Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, 
      New York, New York 10021 USA.
FAU - Christos, Paul J
AU  - Christos PJ
AD  - Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, 
      New York, New York 10021 USA.
FAU - Mangione, Thomas
AU  - Mangione T
AD  - John Snow, Inc., 44 Farnsworth St., Boston, Massachusetts 02210 USA.
FAU - Fins, Joseph J
AU  - Fins JJ
AD  - Weill Cornell Medical College, Division of Medical Ethics, 435 East 70th St. 4J, 
      New York, New York 10021 USA.
LA  - eng
GR  - UL1 TR000457/TR/NCATS NIH HHS/United States
PT  - Journal Article
PT  - Research Support, N.I.H., Extramural
PL  - United States
TA  - J Clin Ethics
JT  - The Journal of clinical ethics
JID - 9114645
SB  - IM
MH  - Adult
MH  - *Attitude of Health Personnel
MH  - *Decision Making
MH  - *Extracorporeal Membrane Oxygenation
MH  - Female
MH  - Humans
MH  - Male
MH  - *Physicians
MH  - Proxy
MH  - Surveys and Questionnaires
MH  - Withholding Treatment/*ethics
PMC - PMC5735424
MID - NIHMS925293
EDAT- 2016/12/22 06:00
MHDA- 2018/03/16 06:00
PMCR- 2017/12/19
CRDT- 2016/12/22 06:00
PHST- 2016/12/22 06:00 [entrez]
PHST- 2016/12/22 06:00 [pubmed]
PHST- 2018/03/16 06:00 [medline]
PHST- 2017/12/19 00:00 [pmc-release]
AID - 2016274281 [pii]
AID - 10.2217/bmm.10.117 [doi]
PST - ppublish
SO  - J Clin Ethics. 2016 Winter;27(4):281-289. doi: 10.2217/bmm.10.117.