The translation of bioethical principles into clinical care can be challenging when those principles conflict, and doubly so when patients are at the end of life. In a post-paternalist era, physicians struggle with finding a balance between respecting a patient’s autonomy while fulfilling their professional duty to act in the patient’s best interest. Hospital policies may provide helpful guidance, but they also may limit physicians’ abilities to do what they believe is medically and ethically best.

Elizabeth Dzeng, MD, MPH, MPhil, MS, is a general internal medicine fellow at the Johns Hopkins School of Medicine and a final year doctoral student in sociology at King’s College, University of Cambridge. She is the lead author on a recent paper published in JAMA Internal Medicine entitled “Influence of Institutional Culture and Policies on Do-Not-Resuscitate Decision Making at the End of Life.” Here, she answers our questions about the impact of institutional culture on what physicians recommend to their dying patients.

Your study found that institutional policies and culture influence doctors’ attitudes towards patient autonomy and their willingness to make clinical recommendations about do-not-resuscitate orders. Why is it important for doctors to make good recommendations at end-of-life?

A key aspect of patient autonomy is that the patient or surrogate has sufficient understanding of the information required to make an informed decision. Studies have shown that for a variety of reasons, patients often do not have all the information needed to make informed decisions. Society’s shift towards autonomy was intended to empower patients but reluctance to make clinically relevant recommendations risks harming patients in the name of autonomy.

Making these decision without guidance or without necessary information can be overwhelming to patients or surrogates, and can cause harm if decisions made are not consistent with the patients’ goals and values. Inappropriate resuscitation can prolong suffering and deprive the dying from a peaceful, dignified death surrounded by family rather than by doctors pounding on their chest. Surrogates who are asked to make decisions on behalf of their loved ones can experience tremendous burden, guilt, and emotional trauma which can be alleviated by a caring physician who is able to provide recommendations and guide them towards a decision that honors the patient’s goals and values.

Did you find that experience seems to change physicians’ susceptibility to institutional culture?

It seemed that as physicians become more experienced, they develop a professional confidence that allows them to feel empowered to act according to their own moral compass, despite policies or cultures that incentivized not doing so. This would for example entail strongly recommending against resuscitation that would have a negligible benefit for the patient. They have learn through experiences with patients – what worked and what didn’t – that the idea of autonomy as merely giving choices is overly simplistic.

I’d like to note that institutional culture should not be seen as something that one is “susceptible” to, but rather an environment that inevitably shapes who we are and what we become. It should be recognized as something that universally influences our attitudes and behaviors. Recognition of this helps us identify ways that we can improve and intervene upon influences that run counter to delivering optimal patient care and instead foster cultures that promote best practices.

Is it a problem that trainees are likelier to respond to institutional culture?

As I discussed in the previous question, I do not feel that institutional culture is a problem, but rather that we must draw attention to its inherent influence on how we learn and develop ethical attitudes and beliefs. There is much emphasis on didactic teaching and role models in medical education but we must also be cognizant of the influence of the hidden curriculum, which transmits attitudes and behaviors through everyday interactions. A person’s understanding of ethical principles and how they act based on them are strongly influenced by their environment both inside and outside of the hospital.

Do laws have an impact on the options available to doctors and patients at end-of-life?

In the paper, I mentioned that the research methods employed did not allow for a determination of the exact interaction between policies and culture. My informal observations lead me to hypothesize that the cultures of the hospitals in New England and the UK are strongly influenced by policies. In the UK, national policies govern practices at local hospitals, although local variations are still known to exist. In New York, state laws very strongly defend patient autonomy and hospitals are required to be adherent. As such, policies have a greater effect on these hospitals’ cultures than vice versa.

In contrast, from informal conversations with key informants at the hospital in the Pacific North-West, it appears that their policies were developed to reflect their existing hospital culture. This heterogeneity illustrates the complexity of the interactions between cultures and policies at different institutions.

What do you hope to see change as a result of your work on this issue?

While we should never look back towards the medical paternalism of days past, I believe that the pendulum has swung too far towards a focus on patient autonomy at the expense of other important principles such as acting in a patient’s best interest and respect for person. I would like to see physicians think of autonomy as more than offering a menu of choices, but rather a shared responsibility to develop a treatment plan that balances clinical risks and benefits in ways that are most likely to honor the patient’s goals and values. Autonomy should mean more engagement, not less. I also hope that this study raises awareness of the importance of culture in affecting our attitudes and beliefs about how medicine is practices.

Dzeng E, Colaianni A, Roland M, Chander G, Smith TJ, Kelly MP, Barclay S, Levine D. Influence of Institutional Culture and Policies on Do-Not-Resuscitate Decision Making at the End of Life.
JAMA Internal Medicine 2015 Apr 6  doi: 10.1001/jamainternmed.2015.0295.
[Epub ahead of print]

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