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1 Department of Family Medicine, University of North Carolina, Chapel Hill, NC
2 Institute for Research in Extramural Medicine (EMGO), and Departments of Nursing Home Medicine and Public and Occupational Health, VU University Medical Center, Amsterdam, the Netherlands
3 Program on Aging, Disability, and Long-Term Care, Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
CORRESPONDING AUTHOR: Margaret R. Helton, MD., Department of Family Medicine, CB # 7595, University of North Carolina, Chapel Hill, NC 27599-7595, margaret_helton{at}med.unc.edu
PURPOSE We wanted to explore factors that influence Dutch and US physician treatment decisions when nursing home patients with dementia become acutely ill with pneumonia.
METHODS Using a qualitative semistructured interview study design, we collected data from 12 physicians in the Netherlands and 12 physicians in North Carolina who care for nursing home patients. Our main outcome measures were perceptions of influential factors that determine physician treatment decisions regarding care of demented patients who develop pneumonia.
RESULTS Several themes emerged from the study. First, physicians viewed their patient care roles differently. Dutch physicians assumed active, primary responsibility for treatment decisions, whereas US physicians were more passive and deferential to family preferences, even in cases when they considered families’ wishes for care as inappropriate. These family wishes were a second theme. US physicians reported a perceived sense of threat from families as influencing the decision to treat more aggressively, whereas Dutch physicians revealed a predisposition to treat based on what they perceived was in the best interest of the patient. The third theme was the process of decision making whereby Dutch physicians based decisions on an intimate knowledge of the patient, and American physicians reported limited knowledge of their nursing home patients as a result of lack of contact time.
CONCLUSION Physician-perceived care roles regarding treatment decisions are influenced by contextual differences in physician training and health care delivery in the United States and the Netherlands. These results are relevant to the debate about optimal care for patients with poor quality of life who lack decision-making capacity.
Key Words: Dementia • nursing home medicine • pneumonia • palliative care • end of life care • euthanasia, passive
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