Legal Defensiveness-Induced Life-Sustaining Treatment: Results of a Natural Experiment

Abstract

Background: Although great attention has been paid to futile life-sustaining treatment (LST), little is known as to whether decreasing a physician’s legal defensiveness could decrease LST. Focusing on the legally defensive attitude toward forgoing LST, whether a decrease in a physician’s legal defensiveness could decrease the use of legally high-risk LST was examined through quasi experimental quantitative analyses under the natural experimental circumstances brought about by two landmark court decisions.

Materials and Methods: After reviewing previous studies regarding defensiveness medicine and legal defensiveness, a conceptual framework for a legal defensiveness model was developed for this study and from the model, the study design for quantitative analyses was drawn. This study used the National Health Insurance Service Elderly Cohort (NHIS-NSEC) which consisted of 588,147 Korean participants older than 60 years in 2002. From the NHIS-NSEC, 73,096 decedents who died during 2003–2013 owing to cancer, circulatory, or respiratory diseases were selected as study subjects. Time series were constructed by time units of a quarter from 2003 to 2013 and divided into periods of increasing, conflicting, and relieving periods according to the level of physicians’ legal defensiveness toward forgoing LST. Within the time series, trends and changes in legally high-risk (physician-driven) LST including cardiopulmonary resuscitation (CPR) and mechanical ventilation (MV) provided during the last 30 days of life were measured and compared between three periods by interrupted time series with segmented regression. Admission to hospitals and per capita hospital days were used as control outcomes (patient-driven) for comparison. Annual increasing rate (AIR) of outcomes during each period and ratio of AIR and outcome level along with 95% confidence intervals were estimated with a generalized linear model with a Poisson distribution and robust standard error.

Results: During the study period, CPR and MV were administered to 7,809 (11.1%) and 11,863 (16.8%) decedents, respectively, during their last 30 days of life. The risk of receiving CPR during the last 30 days of life increased 11.9% per year (AIR 1.119, 95% CI 1.082–1.158), decreased 6.1% per year (AIR 0.939, 95% CI 0.899–0.981), and maintained the same level (RR 1.009, 95% CI 0.982–1.038) during the periods of increasing, conflicting, and relieving legal defensiveness, respectively. The risk of receiving MV during the last 30 days of life increased 8.3% per year (AIR 1.083, 95% CI 1.055–1.112) during the increasing period of legal defensiveness, then maintained the same level during the conflicting (AIR 1.017, 95% CI 0.982–1.053) and relieving (AIR 1.000, 95% CI 0.978–1.022) periods of legal defensiveness. In contrast, although AIRs during the conflicting and relieving period were lower than the AIR of the increasing period, the risks of admission to hospitals (12.3%, 3.6%, and 1.1% per year) and per capita hospital days (20.5%, 4.9%, and 2.3% per year) increased during all three periods.

Conclusion: This study provides evidence that physicians’ legal defensiveness toward forgoing LST contributes to administering LST and if a physician’s legal defensiveness can be decreased then defensive LST can also be decreased. However, considerable legal defensiveness still remains and the level of LST needs to be decreased further. Policies that can reduce physician’s legal instabilities should be implemented to reduce defensive LST.

배경: 무의미한 연명치료에 대한 지대한 관심에도 불구하고 의사의 법적 불안정성의 감소가 연명치료의 감소로 이어질 수 있는지에 관하여 알려진 바가 거의 없다. 연명치료 중단 및 보류에 대한 법방어적 태도를 중심으로, 의사의 법방어적 태도가 감소할 경우 연명치료의 시행이 감소하는지를 두 개의 판결에 의하여 형성된 자연실험적 상황에 대한 유사실험적 연구설계를 통하여 분석하였다.

대상 및 방법: 방어의료 및 법방어적 태도에 관한 선행연구를 종합하여 법방적적 태도 모형을 위한 개념적 틀을 제시하고, 이로부터 계량적 분석을 위한 연구설계를 도출하였다. 연구자료는 2002년에 60세 이상이었던 노인 588,147명으로 구성된 국민건강보험공단 노인코호트를 사용하였다. 노인코호트로부터 2003년부터 2013년 사이에 암, 순환기 및 호흡기 질환으로 사망한 70세에서 89세까지의 노인 73,096명을 연구대상자로 선정...