A Cross-Cultural Study of Physician Treatment Decisions for Demented Nursing Home Patients Who Develop Pneumonia

Cross-cultural studies can provide both a better understanding of differences between countries and refreshing new views on the usual practices. The study by Helton et al., which explored differences in treatment decisions between US and Dutch nursing home (NH) physicians when demented nursing home patients develop pneumonia is a fine example of such a cross- cultural study.[1]

Although both US and Dutch NH physicians shared the belief that nonaggressive care was sometimes appropriate when demented nursing home patients developed pneumonia, important differences with regard to treatment decisions were observed. Firstly, differences existed in views on physicians’ patient care roles. Dutch physicians were more active and assumed primary responsibility for treatment decisions, whereas US physicians were more passive and followed family preferences. Secondly, important differences were observed in the way family wishes were perceived. US physicians often felt a sense of threat, whereas Dutch physicians didn’t feel threaten and sometimes didn’t even follow the family wishes when they perceived these wishes not to be in the best interest of their patients. And finally, treatment decisions of Dutch physicians were often based on an intimate knowledge of their patients, whereas US physicians mostly reported limited knowledge due to lack of contact time. Based on these results, the authors suggest in their discussion that Dutch NH physicians exhibit paternalism toward patients and their families and would need to consider a less paternalistic approach to their care. Introduction of the ‘enhanced autonomy’ model of Quill and Brody could improve the Dutch decision making process and is advised.[2]

However, the model Quill and Brody propose closely resembles the way Dutch NH physicians are working nowadays and therefore will not alter the alleged ‘paternalistic’ acting of Dutch NH physicians. In our opinion ‘paternalism’ does not appropriately describe the practice of Dutch NH physicians. The main problem here is a difference in perceptions between the US and the Netherlands about the physicians’ role and the physicians’ professional autonomy. Is the role of the physician merely to offer opportunities for diagnosis and treatment, and does the patient or the surrogate decision maker have the right and the duty to choose one of the opportunities (US)? Or is the physician’s role to not merely offer opportunities for diagnosis and treatment but to also advise which choices are the best (the Netherlands)? In the Netherlands patients feel entitled to receive professional advice from their physicians and physicians invest a lot of time and effort in advance care planning with patients and their surrogate decision makers. These circumstances direct physicians to another way of practicing than in the US.

Yet there also is another cultural difference that plays a role here. We believe that physicians (but also patients and surrogate decision makers) in the Netherlands have a different view on futility than their US counterparts. In the Netherlands the appropriateness or futility of medical interventions is always related to the overall goal of care as documented in the individual care plan that is agreed upon by the patient and his health care proxy.[3] Further exploration about how physicians, patients and surrogate decision makers are thinking and discussing about ‘futility’ of diagnostic and treatment options in patients with dementia who develop pneumonia in both countries would be very useful.

[1] Helton MR, van der Steen JT, Daaleman TP, Gamble GR, Ribbe MW. A cross-cultural study of physician treatment decisions for demented nursing home patients who develop pneumonia. Ann Fam Med 2006; 4(3):221-7. [2] Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med 1996;125:763-769. [3] Hertogh CMPM, Ribbe MW. Ethical aspects of medical decision-making in demented patients: a report from the Netherlands. Alzheimer Dis Assoc Disord 1996;10:11-9.

Competing interests:   None declared

Dear Professor Lamberts,

Thank you for your interest in our article. As a family physician myself, I admire the role of the huisarts in the Dutch system of medicine and on behalf of my co-authors I welcome your comments and admire your perspective.

In both the Netherlands and the US, family physicians provide a broad range of care. Our intention was not to compare family physicians in the two countries, rather we were interested specifically in the management of patients with dementia who reside in nursing homes. It just so happens that in the US, physicians who care for such patients are family physicians and internists and in the Netherlands such care is the domain of the nursing home physician.

Whether or not our conclusions apply to the Dutch huisarts caring for a demented patient outside a nursing home is unclear. For that matter, the conclusions may not apply to American physicians who are providing home care either. We focused on nursing home care because that is a setting where hospital transfer seems often unnecessary, given the treatment capabilities already in place in such an institutional setting.

You explained that in the Netherlands the vast majority of patients with pneumonia and/or dementia reside at home and that the central role of the huisarts allows the majority of patients with dementia to die at home. I will need to confer with my Dutch colleagues on those figures, but in the US most patients with dementia die in a nursing home. Nursing home patients with dementia have an incident rate of pneumonia of 370 per 1000 patient years (Muder, et.al) which is higher than the rates of 36-46 per 1000 patient years that you quoted. It may reflect the fact that the patients in nursing homes are more severely afflicted with dementia and have a higher likelihood of pneumonia.

We did indeed touch briefly on the subject of euthanasia, mainly to provide societal context in the realm of end-of-life care. We do understand that this is primarily the realm of the huisarts and that it is uncommon for dementia to be the primary indication.

We appreciate your vigorous argument that Dutch huisarts are not paternalistic. We have learned in the past week that the word “paternalistic” comes across as more negative in Dutch than in English, where it can actually reflect some amount of beneficence. Had we known how the word would be perceived to a Dutch reader, we might have chosen the word “directive” rather than “paternalistic.” Such are the nuances of language. However, it must also be recognized that many of the Dutch physicians did make comments that could be perceived as presenting a position of non-negotiation.

It is our hope that vigorous discussions on these issues can lead to better care on both sides of the ocean. We admire the Dutch system of health care – the central role of the huisarts and the unique arrangement of having physicians trained specifically for nursing home care. We hope to draw lessons from both.

Thank you again for your comments.

Sincerely,

Margaret R. Helton, MD University of North Carolina Chapel Hill, NC

Competing interests:   None declared