Doctors' knowledge of the law on withholding and withdrawing life-sustaining medical treatment

To the Editor: Unfortunately, the research performed by White and colleagues1 appears to be flawed by selection bias. This is the result of their failure to survey specialists in general medicine, who regularly make decisions on the withholding and withdrawing of life-sustaining medical treatment. Therefore, the findings of the survey may not accurately reflect real legal understanding among the specialists in our health system most frequently required to make these kinds of decisions. General physicians' patients frequently require careful evaluation of any pre-existing advance care directives, and discussion with statutory health attorneys relating to decisions regarding the provision or withholding of life-sustaining treatment.

In our view, most general physicians are very aware of the legal implications of such decisions, being required to regularly assess the capacity of patients with multimorbidity, frailty and cognitive impairment to consent to treatment, and to provide or withhold life-sustaining therapy. In addition, they use this knowledge in discussions with relatives and friends, especially when families disagree on the appropriate measures to be taken. General physicians also provide informal training of junior medical officers and medical students in the application of the law to end-of-life care, and in assessing medical futility and the wishes of patients or their statutory health attorneys.

White et al should repeat their evaluation to ensure that the mix of specialties surveyed accurately represents the services that provide care for patients when knowledge of the local law is most relevant and critical. Education and training can then be more appropriately reinforced in programs where they might have the greatest benefit.