The Influence of Hospital Policies on Clinicians' Decisions to Withhold or Withdraw Life-sustaining Treatment.

Abstract

BACKGROUND There is considerable variation in clinicians' approaches to decisions to withhold or withdraw life sustaining treatment (LST) across US hospitals. These differences are not explained by patient preferences alone and are likely influenced by other factors such as hospital policies, hospital culture, state laws, and medical society guidelines. RESEARCH QUESTION How do hospital policies influence clinician approaches to decisions to withhold or withdraw LST among patients admitted to an intensive care unit (ICU)? STUDY DESIGN AND METHODS We conducted semi-structured interviews with ICU nurses and physicians at three geographically diverse hospital systems across the United States between July and October 2024. We asked clinicians about their experiences with, and perceptions of, hospital policies on withholding or withdrawing LST and the relationship between these policies and clinician decision-making in ethically challenging scenarios. RESULTS We interviewed ten nurses and eight attending physicians with median 5 years (range 2-36 years) in practice. Clinicians described limited awareness of, and familiarity with, their hospital's policies that addressed withholding or withdrawing LST. Clinicians with knowledge of these policies could identify their location but described barriers to accessing them. While clinicians perceived hospital policies as helpful in some ways (e.g., legal protection and ethical guidance), they viewed them as neither acknowledging nor addressing sociodemographic disparities or clinician value judgments in LST decision-making. Perceptions varied about whether clinicians followed their own hospital policy guidance when making decisions to withhold or withdraw LST. INTERPRETATION Clinicians lack detailed understanding about their hospitals' policies that address withholding or withdrawing LST and perceive these policies as having limited applicability to clinical practice. These findings suggest that hospital policies may have little influence on clinician behavior in addressing decisions to withhold or withdraw LST in ethically challenging scenarios.