- Email: [email protected]
Medical end-of-life decisions in Norway
Resuscitation 57 (2003) 311 /318 www.elsevier.com/locate/resuscitation
Letters to the Editor
Medical end-of-life decisions in Norway A recent paper in Resuscitation entitled ‘‘Medical end-of-life decisions in Norway’’ by Forde et al. [1] has caused widespread distress among Norwegian anesthesiologists. This is due to a seemingly minor set of data in the paper, but which relates directly to the purpose of the study: to uncover euthanasia practice and attitudes of Norwegian physicians. Among 1298 respondents to a questionnaire on care at the end of life, 13 physicians replied ‘‘yes’’ to the following question. ‘‘Have you as a physician ever committed an act (for example given an injection) with the explicit purpose of shortening the life of a patient? (Do not include termination of life-sustaining treatment to dying patients)’’. Among these 13 physicians there were three anesthesiologists (out of a total number of 55; i.e. 33 specialists and 22 in training). The paper actually states that the numbers were four out of 40 anesthesiologists, but the authors have informed us that these numbers are erroneous, as are also several other numbers and confidence intervals (Appendix A). All respondents were divided into eight specialty categories, of which anesthesiology comprised one. The authors for some odd reason chose to present the results for only this category (anesthesiology) separately. Such presentation of the data seems to us biased and speculative. When comparing the frequency of affirmative responses in this group (3/55 or 5.5%) with those of the seven other specialty categories merged together (10/ 1258 or 0.8%), the authors find wide 95% confidence intervals (1.4 /16.7 and 0.5 /15.3, respectively, but these are incorrect). The authors have used sophisticated statistical methods to analyze these meager data. Unsurprisingly, this analysis shows that on the basis of such small numbers it is not possible either to confirm or reject a hypothesis that anesthesiologists are more prone to commit an act of euthanasia than their peers in other specialties. The 1298 (or was it actually 1318, the numbers are confusing) respondents were among 1616 physicians who received the questionnaire. Thus, around 300 did not respond. We may assume that among the respondents several did not answer with the enthusiasm and interest the authors would have preferred; after all, the
15-page questionnaire contained more than 70 questions. If only a small fraction (e.g. 1%) of respondents has slightly misinterpreted the question, this will strongly affect the results. Have the authors sought to validate or confirm the answers in any way? These are relevant concerns because in Norway, as in most civilized countries, euthanasia is illegal. We find it surprising that the authors do not at all discuss such possible limitations of their data. Thus, the only conclusion that can possibly be drawn from these data is that about 1% of the respondents have answered in the affirmative and that this number is strongly prone to statistical and methodological error. We have also noted other serious errors. The abstract reads: ‘‘83% responded. A total of 8.1% had terminated life-prolonging treatment based on the resource situation, while 53.5 and 40.1%, respectively, had stopped life prolonging treatment due to the wish of the patient and the wish of the patient’s relatives’’. In the context of the abstract it is clear that the percentages should refer to proportions of all respondents (N /1318). However, after reading the results section number 3.2 carefully, we find that the presented numbers are percentages of a sub-group (n/883, 67% of respondents (not 69% as stated in the paper)). Thus, correct percentages are 5.5, 35.8 and 26.9% instead of 8.1, 53.5 and 40.1%, respectively. The authors repeat the erroneous numbers in the discussion without stating that they derive from a subgroup. It follows that these results are not representative for the population described. Following publication in Resuscitation the paper received great attention from the Norwegian press. Based on the percentage (i.e. 5.5%) of affirmative responses (n /3) to the ‘‘euthanasia-question’’, this resulted in screaming headlines in the nation’s leading newspaper saying, ‘‘one out of every 20 Norwegian anesthesiologists admits to having committed euthanasia’’. Those in favor of physician-assisted suicide as well as other Scandinavian press agencies have already repeated the numbers. The erroneous numbers cited above, on termination of life-sustaining treatment, were also repeated. We think that the authors are to be blamed for speculative and biased presentation of insufficient data. They are also to blame for poor quality control causing several confusing and erroneous numbers and calculations to occur throughout the paper. This criticism also
0300-9572/03/$ - see front matter # 2003 Elsevier Science Ireland Ltd. All rights reserved.
312
Letters to the Editor
extends to the editors of Resuscitation and calls to attention the editorial process to which this paper has been subjected. Lastly, the authors are to blame for their unprofessional handling of the press who was (unnecessarily) called upon by the authors and who should have been better guided through the paper. It is our firm opinion that this paper should not have been published. We, therefore, suggest it be withdrawn. Appendix A: Errors, flaws and miscalculations in the paper by Forde et al. Errors relating to sample size. Table 1 and section # 3.1 clearly states that N /1318 and that 1318 completed and 27 blank forms were returned (out of a total of 1616). This gives a response rate of 81.5%, not 83%. # 3.2. ‘‘For 31% of the physicians [. . .] of the remaining 883 (69%) physicians. . .’’ 31% of 1318 can broadly be interpreted as an integer somewhere between 402 and 414. This number should have been 435, if there are 883 ‘‘remaining’’ to add up to a total of 1318. On the other hand 883 would be 69% of an integer between 1271 and 1289. This does not compare well with any of the three alternatives in section 3.3 (see below). # 3.3. ‘‘One percent, 13/1298, all men. . .’’ Thus 20 are missing from the original sample of 1318. Further in section 3.3 it says that 10/1258 non-anesthesiologists and 4/40 anesthesiologists have committed euthanasia. The authors, however, have informed us that the numbers for anesthesiologists should read 3/55. In that case the total sample is 1313. Which sample size is correct, 1298, 1313 or 1318? # 3.4. Here sample size is given as 1295. Table 1: The number of respondents in different age groups is given as percentages. Using conventional rounding we find that there were 239, 348, 411 and 308 physicians in the different groups. The sum of these figures is 1306, not 1318. Similarly, the categorization into senior consultants, junior registrars, GPs etc. adds up to 1308 and the categorization into specialist and non-specialist categories adds up to 1316. The reason for these discrepancies may simply be that going from absolute numbers to percentages and back to absolute numbers will always yield inconsistencies (see # 3.2, above). However, this underlines the importance of providing absolute numbers in tables like this. Errors relating to proportions and confidence intervals. # 3.3. 4/40 should read 3/55 (according to the authors, see above). This gives a percentage of 5.45 with confidence limits of 1.1 /15.1, not 1.4 /16.7. For the proportion 10/1258, the confidence limits are 0.4 /1.5, not 0.5 /15.3, thus the true upper confidence limit is smaller than the one reported by one order of magnitude.
Misrepresentation of data. In the context of the abstract it is clear that the percentages cited should refer to proportions of all respondents (N /1318). However, after reading the results section # 3.2 carefully, we find that the presented numbers are percentages of a sub-group (n/883, 67% of respondents (not 69% as stated in the paper)). Thus, correct percentages are 5.5, 35.8 and 26.9% instead of 8.1, 53.5 and 40.1%, respectively. The authors repeat the erroneous numbers in the discussion without stating that they derive from a subgroup. It follows that these results are not representative for the population described. Table 2: The subgroup of male-physicians, 50/54 years has here been singled out without any explanation whatsoever. The basis for the estimations in the table is probably the subgroup (N /883) mentioned in the paragraph above but without this being explained. Methods section: Respondents are grouped into eight subcategories of which non-specialists and anesthesiologists are two. For the data in Tables 1 and 2 and most results, this classification seem to have been the basis for analysis. When analyzing the ‘‘euthanasia-question’’ the authors have strayed from the methods and merged trainee anesthesiologist and specialists without any explanation. References [1] Forde R, Aasland OG, Steen PA. Medical end-of-life decisions in Norway. Resuscitation 2002;55:235 /240
Jon Henrik Laake, Audun Stubhaug Department of Anaesthesiology, National Hospital (Rikshospitalet), 0027 Oslo, Norway E-mail address: [email protected] Reply to Jon Henrik Laake and Auduu Stubhaug We appreciate that this paper has received the attention of Laake and Stubhaug as it presents data from a large group of physicians on important ethical issues. We had hoped for a discussion on these underlying ethical issues. As anaesthesiologists are often in charge of pain treatment and terminal care, their results were pointed out in the text, and the data published in a journal with high anaesthesia readership. Oncology could have been another candidate, but the group was too small. With 55 anaesthesiologists, 33 specialists and 22 in training, we found the group large enough to do some separate analyses. We regret that in proof reading we did not spot the error that the correct proportion in the last line on
Letters to the Editor
page 237 should be 3/55, not 4/40. The percentage of 5.5 % and the numbers used in the statistical analyses were correct. We clearly point out that there is no statistically significant difference, neither with bivariate (grossly overlapping confidence intervals) nor multivariate (with gender and age as covariates, data not shown) analysis. The impact of the headline (beyond our control) in a major newspaper focusing on the data for the anaesthesiologists is hopefully reduced in our published letter to the editor of that newspaper. Contrary to Laake and Stubhaug we do not consider calculation of proportions with confidence intervals as ‘‘sophisticated statistical methods’’. Different algorithms are used to adjust for proportions close to 0 or 1, which may give slightly different results. In our case we have used Yate’s continuity correction, and this should be in accordance with some major (also Norwegian) authorities on statistics. The number of respondents in this survey was 1318, which is the number used in table 1 to compare with the complete Norwegian physician workforce. However, not all respondents answered every question, which is why we operate with slightly different proportions in the paper. For some questions we included the response option ‘not applicable’, since many doctors have jobs where they hardly see patients, or do not have to prioritise for other reasons. This is duly explained in the paper. We disagree that the number of respondents answering ‘‘not applicable’’ should have been included in the total for each question in the abstract. We maintain that 3/55 vs. 4/40 in the presentation does not qualify for ‘several confusing and erroneous numbers and calculations’. Laake and Stubhaug also indicate that respondents could have misinterpreted the question. We do not believe that our colleagues are likely to misinterpret: ‘‘Have you as a physician ever committed an act (for example given an injection) with the explicit purpose of shortening the life of a patient? (Do not include termination of life-sustaining treatment to dying patients).’’ Laake and Stubhaug suggests that a ‘‘yes’’ should have been further validated, and Laake has in a personal communication suggested a repeat question after explaining to the respondents that a ‘‘yes’’ is a ‘‘yes’’ to a serious crime. In our opinion it would have made it more difficult to interpret the results after thus potentially characterizing the respondents. The rest of the letter from Laake and Stubhaug including their accusations of speculative and biased presentation is beyond what we find it appropriate to respond to. But we do hope that this interchange can cause some to reread our article and stimulate further debate on the difficult ethical issues involved, such as the termination of life-prolonging treatment due to lack of resources.
313
Olaf G. Aasland Reidun Førde Petter Andreas Steen Note from the Editor-in-Chief At their request we publish a letter from Jon Laake and Audun Staubhaug from Norway who complain about the results found by Forde, Aaland and Steen in their paper on Medical End of Life Decisions published recently in the journal (Resuscitation 2002;55:235 / 240). There is also a dignified and informative reply by Forde, Aaland and Steen. Clearly the results of the original paper are not to the liking of Laake and Staubhaug as judged by the tone of their letter but that does not mean that the paper should not have been published. After careful review of all the points made, I am quite satisfied that the paper was correctly written and the points made are quite valid as explained. The paper was reviewed by experts in the field. Publication was entirely justified and the original will not be withdrawn. Correspondence on this matter is now closed. Peter Baskett Editor-in-Chief doi:10.1016/S0300-9572(03)00120-5
Transient right bundle branch block unmasking anterior myocardial infarction In right bundle branch block (BBB), the early QRS forces are not usually affected because the septum is activated normally in a left-to-right direction. Therefore, it is assumed that the right BBB does not interfere with the electrocardiographic diagnosis of myocardial infarction (MI). However, occasional case reports have shown that a right BBB may develop transient Q waves in right precordial leads, especially in patients with anterior MI [1 /6]. We report a patient who had right BBB-dependent Q waves in precordial leads unmasking previous anterior MI. A 82-year-old man was admitted to the Intensive Care Unit because of dizziness and chest discomfort due to ventricular tachycardia. Subsequent physical and laboratory evaluation excluded an acute coronary syndrome. Fourteen years earlier, the patient had had a Qwave anterior MI. Once the ventricular tachycardia was suppressed with synchronized cardioversion, the ECG (Fig. 1) revealed normal sinus rhythm at 75 beats/min with PR-interval of 0.28 s. There were two different types of wide (/0.16 s) QRS complexes: (1) those marked by a white arrow showed severe conduction delay in the left bundle branch system; and (2) the other
Letters to the Editor
Medical end-of-life decisions in Norway A recent paper in Resuscitation entitled ‘‘Medical end-of-life decisions in Norway’’ by Forde et al. [1] has caused widespread distress among Norwegian anesthesiologists. This is due to a seemingly minor set of data in the paper, but which relates directly to the purpose of the study: to uncover euthanasia practice and attitudes of Norwegian physicians. Among 1298 respondents to a questionnaire on care at the end of life, 13 physicians replied ‘‘yes’’ to the following question. ‘‘Have you as a physician ever committed an act (for example given an injection) with the explicit purpose of shortening the life of a patient? (Do not include termination of life-sustaining treatment to dying patients)’’. Among these 13 physicians there were three anesthesiologists (out of a total number of 55; i.e. 33 specialists and 22 in training). The paper actually states that the numbers were four out of 40 anesthesiologists, but the authors have informed us that these numbers are erroneous, as are also several other numbers and confidence intervals (Appendix A). All respondents were divided into eight specialty categories, of which anesthesiology comprised one. The authors for some odd reason chose to present the results for only this category (anesthesiology) separately. Such presentation of the data seems to us biased and speculative. When comparing the frequency of affirmative responses in this group (3/55 or 5.5%) with those of the seven other specialty categories merged together (10/ 1258 or 0.8%), the authors find wide 95% confidence intervals (1.4 /16.7 and 0.5 /15.3, respectively, but these are incorrect). The authors have used sophisticated statistical methods to analyze these meager data. Unsurprisingly, this analysis shows that on the basis of such small numbers it is not possible either to confirm or reject a hypothesis that anesthesiologists are more prone to commit an act of euthanasia than their peers in other specialties. The 1298 (or was it actually 1318, the numbers are confusing) respondents were among 1616 physicians who received the questionnaire. Thus, around 300 did not respond. We may assume that among the respondents several did not answer with the enthusiasm and interest the authors would have preferred; after all, the
15-page questionnaire contained more than 70 questions. If only a small fraction (e.g. 1%) of respondents has slightly misinterpreted the question, this will strongly affect the results. Have the authors sought to validate or confirm the answers in any way? These are relevant concerns because in Norway, as in most civilized countries, euthanasia is illegal. We find it surprising that the authors do not at all discuss such possible limitations of their data. Thus, the only conclusion that can possibly be drawn from these data is that about 1% of the respondents have answered in the affirmative and that this number is strongly prone to statistical and methodological error. We have also noted other serious errors. The abstract reads: ‘‘83% responded. A total of 8.1% had terminated life-prolonging treatment based on the resource situation, while 53.5 and 40.1%, respectively, had stopped life prolonging treatment due to the wish of the patient and the wish of the patient’s relatives’’. In the context of the abstract it is clear that the percentages should refer to proportions of all respondents (N /1318). However, after reading the results section number 3.2 carefully, we find that the presented numbers are percentages of a sub-group (n/883, 67% of respondents (not 69% as stated in the paper)). Thus, correct percentages are 5.5, 35.8 and 26.9% instead of 8.1, 53.5 and 40.1%, respectively. The authors repeat the erroneous numbers in the discussion without stating that they derive from a subgroup. It follows that these results are not representative for the population described. Following publication in Resuscitation the paper received great attention from the Norwegian press. Based on the percentage (i.e. 5.5%) of affirmative responses (n /3) to the ‘‘euthanasia-question’’, this resulted in screaming headlines in the nation’s leading newspaper saying, ‘‘one out of every 20 Norwegian anesthesiologists admits to having committed euthanasia’’. Those in favor of physician-assisted suicide as well as other Scandinavian press agencies have already repeated the numbers. The erroneous numbers cited above, on termination of life-sustaining treatment, were also repeated. We think that the authors are to be blamed for speculative and biased presentation of insufficient data. They are also to blame for poor quality control causing several confusing and erroneous numbers and calculations to occur throughout the paper. This criticism also
0300-9572/03/$ - see front matter # 2003 Elsevier Science Ireland Ltd. All rights reserved.
312
Letters to the Editor
extends to the editors of Resuscitation and calls to attention the editorial process to which this paper has been subjected. Lastly, the authors are to blame for their unprofessional handling of the press who was (unnecessarily) called upon by the authors and who should have been better guided through the paper. It is our firm opinion that this paper should not have been published. We, therefore, suggest it be withdrawn. Appendix A: Errors, flaws and miscalculations in the paper by Forde et al. Errors relating to sample size. Table 1 and section # 3.1 clearly states that N /1318 and that 1318 completed and 27 blank forms were returned (out of a total of 1616). This gives a response rate of 81.5%, not 83%. # 3.2. ‘‘For 31% of the physicians [. . .] of the remaining 883 (69%) physicians. . .’’ 31% of 1318 can broadly be interpreted as an integer somewhere between 402 and 414. This number should have been 435, if there are 883 ‘‘remaining’’ to add up to a total of 1318. On the other hand 883 would be 69% of an integer between 1271 and 1289. This does not compare well with any of the three alternatives in section 3.3 (see below). # 3.3. ‘‘One percent, 13/1298, all men. . .’’ Thus 20 are missing from the original sample of 1318. Further in section 3.3 it says that 10/1258 non-anesthesiologists and 4/40 anesthesiologists have committed euthanasia. The authors, however, have informed us that the numbers for anesthesiologists should read 3/55. In that case the total sample is 1313. Which sample size is correct, 1298, 1313 or 1318? # 3.4. Here sample size is given as 1295. Table 1: The number of respondents in different age groups is given as percentages. Using conventional rounding we find that there were 239, 348, 411 and 308 physicians in the different groups. The sum of these figures is 1306, not 1318. Similarly, the categorization into senior consultants, junior registrars, GPs etc. adds up to 1308 and the categorization into specialist and non-specialist categories adds up to 1316. The reason for these discrepancies may simply be that going from absolute numbers to percentages and back to absolute numbers will always yield inconsistencies (see # 3.2, above). However, this underlines the importance of providing absolute numbers in tables like this. Errors relating to proportions and confidence intervals. # 3.3. 4/40 should read 3/55 (according to the authors, see above). This gives a percentage of 5.45 with confidence limits of 1.1 /15.1, not 1.4 /16.7. For the proportion 10/1258, the confidence limits are 0.4 /1.5, not 0.5 /15.3, thus the true upper confidence limit is smaller than the one reported by one order of magnitude.
Misrepresentation of data. In the context of the abstract it is clear that the percentages cited should refer to proportions of all respondents (N /1318). However, after reading the results section # 3.2 carefully, we find that the presented numbers are percentages of a sub-group (n/883, 67% of respondents (not 69% as stated in the paper)). Thus, correct percentages are 5.5, 35.8 and 26.9% instead of 8.1, 53.5 and 40.1%, respectively. The authors repeat the erroneous numbers in the discussion without stating that they derive from a subgroup. It follows that these results are not representative for the population described. Table 2: The subgroup of male-physicians, 50/54 years has here been singled out without any explanation whatsoever. The basis for the estimations in the table is probably the subgroup (N /883) mentioned in the paragraph above but without this being explained. Methods section: Respondents are grouped into eight subcategories of which non-specialists and anesthesiologists are two. For the data in Tables 1 and 2 and most results, this classification seem to have been the basis for analysis. When analyzing the ‘‘euthanasia-question’’ the authors have strayed from the methods and merged trainee anesthesiologist and specialists without any explanation. References [1] Forde R, Aasland OG, Steen PA. Medical end-of-life decisions in Norway. Resuscitation 2002;55:235 /240
Jon Henrik Laake, Audun Stubhaug Department of Anaesthesiology, National Hospital (Rikshospitalet), 0027 Oslo, Norway E-mail address: [email protected] Reply to Jon Henrik Laake and Auduu Stubhaug We appreciate that this paper has received the attention of Laake and Stubhaug as it presents data from a large group of physicians on important ethical issues. We had hoped for a discussion on these underlying ethical issues. As anaesthesiologists are often in charge of pain treatment and terminal care, their results were pointed out in the text, and the data published in a journal with high anaesthesia readership. Oncology could have been another candidate, but the group was too small. With 55 anaesthesiologists, 33 specialists and 22 in training, we found the group large enough to do some separate analyses. We regret that in proof reading we did not spot the error that the correct proportion in the last line on
Letters to the Editor
page 237 should be 3/55, not 4/40. The percentage of 5.5 % and the numbers used in the statistical analyses were correct. We clearly point out that there is no statistically significant difference, neither with bivariate (grossly overlapping confidence intervals) nor multivariate (with gender and age as covariates, data not shown) analysis. The impact of the headline (beyond our control) in a major newspaper focusing on the data for the anaesthesiologists is hopefully reduced in our published letter to the editor of that newspaper. Contrary to Laake and Stubhaug we do not consider calculation of proportions with confidence intervals as ‘‘sophisticated statistical methods’’. Different algorithms are used to adjust for proportions close to 0 or 1, which may give slightly different results. In our case we have used Yate’s continuity correction, and this should be in accordance with some major (also Norwegian) authorities on statistics. The number of respondents in this survey was 1318, which is the number used in table 1 to compare with the complete Norwegian physician workforce. However, not all respondents answered every question, which is why we operate with slightly different proportions in the paper. For some questions we included the response option ‘not applicable’, since many doctors have jobs where they hardly see patients, or do not have to prioritise for other reasons. This is duly explained in the paper. We disagree that the number of respondents answering ‘‘not applicable’’ should have been included in the total for each question in the abstract. We maintain that 3/55 vs. 4/40 in the presentation does not qualify for ‘several confusing and erroneous numbers and calculations’. Laake and Stubhaug also indicate that respondents could have misinterpreted the question. We do not believe that our colleagues are likely to misinterpret: ‘‘Have you as a physician ever committed an act (for example given an injection) with the explicit purpose of shortening the life of a patient? (Do not include termination of life-sustaining treatment to dying patients).’’ Laake and Stubhaug suggests that a ‘‘yes’’ should have been further validated, and Laake has in a personal communication suggested a repeat question after explaining to the respondents that a ‘‘yes’’ is a ‘‘yes’’ to a serious crime. In our opinion it would have made it more difficult to interpret the results after thus potentially characterizing the respondents. The rest of the letter from Laake and Stubhaug including their accusations of speculative and biased presentation is beyond what we find it appropriate to respond to. But we do hope that this interchange can cause some to reread our article and stimulate further debate on the difficult ethical issues involved, such as the termination of life-prolonging treatment due to lack of resources.
313
Olaf G. Aasland Reidun Førde Petter Andreas Steen Note from the Editor-in-Chief At their request we publish a letter from Jon Laake and Audun Staubhaug from Norway who complain about the results found by Forde, Aaland and Steen in their paper on Medical End of Life Decisions published recently in the journal (Resuscitation 2002;55:235 / 240). There is also a dignified and informative reply by Forde, Aaland and Steen. Clearly the results of the original paper are not to the liking of Laake and Staubhaug as judged by the tone of their letter but that does not mean that the paper should not have been published. After careful review of all the points made, I am quite satisfied that the paper was correctly written and the points made are quite valid as explained. The paper was reviewed by experts in the field. Publication was entirely justified and the original will not be withdrawn. Correspondence on this matter is now closed. Peter Baskett Editor-in-Chief doi:10.1016/S0300-9572(03)00120-5
Transient right bundle branch block unmasking anterior myocardial infarction In right bundle branch block (BBB), the early QRS forces are not usually affected because the septum is activated normally in a left-to-right direction. Therefore, it is assumed that the right BBB does not interfere with the electrocardiographic diagnosis of myocardial infarction (MI). However, occasional case reports have shown that a right BBB may develop transient Q waves in right precordial leads, especially in patients with anterior MI [1 /6]. We report a patient who had right BBB-dependent Q waves in precordial leads unmasking previous anterior MI. A 82-year-old man was admitted to the Intensive Care Unit because of dizziness and chest discomfort due to ventricular tachycardia. Subsequent physical and laboratory evaluation excluded an acute coronary syndrome. Fourteen years earlier, the patient had had a Qwave anterior MI. Once the ventricular tachycardia was suppressed with synchronized cardioversion, the ECG (Fig. 1) revealed normal sinus rhythm at 75 beats/min with PR-interval of 0.28 s. There were two different types of wide (/0.16 s) QRS complexes: (1) those marked by a white arrow showed severe conduction delay in the left bundle branch system; and (2) the other