Legal Defensiveness-Induced Life-Sustaining Treatment: Results of a Natural Experiment
Year: 2017
Type: dissertation
Abstract: Background: Although great attention has been paid to futile life-sustaining treatment (LST), little is known as to whether decreasing a physician�셲 legal defensiveness could decrease LST. Focusing on the legally defensive attitude toward forgoing LST, whether a decrease in a physician�셲 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. \n \nMaterials 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. \n \nResults: 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. \n \nConclusion: This study provides evidence that physicians�� legal defensiveness toward forgoing LST contributes to administering LST and if a physician�셲 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�셲 legal instabilities should be implemented to reduce defensive LST. \n \n \n諛곌꼍: 臾댁쓽誘명븳 �뿰紐낆튂猷뚯뿉 ���븳 吏����븳 愿��떖�뿉�룄 遺덇뎄�븯怨� �쓽�궗�쓽 踰뺤쟻 遺덉븞�젙�꽦�쓽 媛먯냼媛� �뿰紐낆튂猷뚯쓽 媛먯냼濡� �씠�뼱吏� �닔 �엳�뒗吏��뿉 愿��븯�뿬 �븣�젮吏� 諛붽� 嫄곗쓽 �뾾�떎. �뿰紐낆튂猷� 以묐떒 諛� 蹂대쪟�뿉 ���븳 踰뺣갑�뼱�쟻 �깭�룄瑜� 以묒떖�쑝濡�, �쓽�궗�쓽 踰뺣갑�뼱�쟻 �깭�룄媛� 媛먯냼�븷 寃쎌슦 �뿰紐낆튂猷뚯쓽 �떆�뻾�씠 媛먯냼�븯�뒗吏�瑜� �몢 媛쒖쓽 �뙋寃곗뿉 �쓽�븯�뿬 �삎�꽦�맂 �옄�뿰�떎�뿕�쟻 �긽�솴�뿉 ���븳 �쑀�궗�떎�뿕�쟻 �뿰援ъ꽕怨꾨�� �넻�븯�뿬 遺꾩꽍�븯���떎. \n \n���긽 諛� 諛⑸쾿: 諛⑹뼱�쓽猷� 諛� 踰뺣갑�뼱�쟻 �깭�룄�뿉 愿��븳 �꽑�뻾�뿰援щ�� 醫낇빀�븯�뿬 踰뺣갑�쟻�쟻 �깭�룄 紐⑦삎�쓣 �쐞�븳 媛쒕뀗�쟻 ���쓣 �젣�떆�븯怨�, �씠濡쒕��꽣 怨꾨웾�쟻 遺꾩꽍�쓣 �쐞�븳 �뿰援ъ꽕怨꾨�� �룄異쒗븯���떎. �뿰援ъ옄猷뚮뒗 2002�뀈�뿉 60�꽭 �씠�긽�씠�뿀�뜕 �끂�씤 588,147紐낆쑝濡� 援ъ꽦�맂 援�誘쇨굔媛뺣낫�뿕怨듬떒 �끂�씤肄뷀샇�듃瑜� �궗�슜�븯���떎. �끂�씤肄뷀샇�듃濡쒕��꽣 2003�뀈遺��꽣 2013�뀈 �궗�씠�뿉 �븫, �닚�솚湲� 諛� �샇�씉湲� 吏덊솚�쑝濡� �궗留앺븳 70�꽭�뿉�꽌 89�꽭源뚯��쓽 �끂�씤 73,096紐낆쓣 �뿰援щ��긽�옄濡� �꽑�젙...
Author: 장석용
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2954831362