Family Physicians’ Decision-making in Mechanical Ventilation Withdrawal: A Cross-sectional Study

INTRODUCTION

The increase in global life expectancy, with Thailand reaching 75.3 years as of 2021,^[1] has not necessarily translated into improved quality of life. Advances in medical technology often prioritise life extension without adequately addressing patient comfort or wishes, underscoring the importance of palliative care. This care approach emphasises improving quality of life from diagnosis, addressing the holistic needs – physical, emotional, and spiritual – of patients, rather than merely extending life. It respects patient preferences for end-of-life care, including the cessation of life-sustaining interventions, thereby ensuring a dignified and natural passage.

The practice of withdrawing life-sustaining treatment (LST) is not uniform and shows notable variation across different regions globally. Regions such as Australia, North America, Europe, and Africa report a higher prevalence compared to Asia, the Middle East, and South America.^[2] One of the most frequently withdrawn LSTs is mechanical ventilation. According to Damghi et al.^[3] the LSTs most commonly withheld or withdrawn in emergency departments include mechanical ventilation, at 17%, and inotropic support, at 15.8%. Research indicates a significant prevalence of withdrawal of mechanical ventilation (WMV) in intensive care units (ICUs), with rates ranging from 56% to 86%.^[4,5] An interesting observation is that in countries such as the US, Canada, Australia, and Sweden, the occurrences of WMV before death are considerably higher, standing at 19.5% and 17.2%, in contrast to cases where patients remain on ventilation until death.

At present, no standardised criteria or protocols exist for decision-making in the WMV. However, decisions are influenced by a multitude of factors. These include the patient’s prognosis,^[6-8] the severity of the disease,^[6] age,^[7,9,10] and level of consciousness,^[7] as well as the patient’s willingness for WMV^[6,7,10] and the involvement or consent of family or surrogate decision-makers (SDMs). In addition, the physician’s beliefs,^[11,12] knowledge,^[13] experience in palliative care, and views on WMV in the context of assisted dying and its legal implications significantly sway the decision-making process. The existence of a formal withdrawal protocol is also a crucial consideration.

Palliative care in Thailand has evolved since the late 1990s.^[14] From 2011 to 2017, the care system progressed from isolated service delivery to an initial phase of integration into the wider healthcare network, moving from stage 3b to stage 4, according to the Worldwide Hospice Palliative Care Alliance’s classifications.^[15,16] In Thailand, family physicians are central to palliative care delivery, providing a spectrum of services.^[17] Their roles extend beyond primary care to include inpatient consultations across diverse environments such as emergency departments, critical care units, general wards, community centres, and home care. This broad scope means that WMV concerns not only specialists in critical care but also family physicians, who are often the primary caregivers for terminally ill patients. However, the lack of definitive guidelines leads to variation in the reasons among family physicians for initiating WMV. This study’s primary objective is to uncover the factors that influence the WMV decision-making process in terminally ill patients. A secondary goal is to explore family physicians’ attitudes towards WMV in these scenarios.

MATERIALS AND METHODS

RESULTS

In line with the inclusion criteria, all respondents had experience in palliative care, which may have been gained through formal training or solely through clinical practice. A total of 173 family physicians responded; nine were excluded for not meeting the inclusion criteria, leaving 164 participants for final analysis [Figure 1]. Among these, 61% were female, with an average age of 34.6 years, and 92.68% identified as Buddhist. On average, respondents reported 5 years of practice in family medicine and 5.15 years of experience in palliative care. Most participants (95%) had undergone formal palliative care training, and 68.29% reported receiving specific training in WMV. Notably, 75% had experience in WMV [Table 1].

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Figure 1:

Participant recruitment and selection process.

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Our subsequent comparative analysis indicated the presence of significant differences between the physicians who had experience in WMV and those who did not. These variations were particularly evident in factors such as the duration of experience in palliative care, with a specific focus on whether they had at least 3 years of such experience, and their training history in both palliative care and procedures for WMV. [Further details are provided in Table 1].

DISCUSSION

This study aims to identify key factors influencing family doctors’ decision-making processes regarding the WMV in terminally ill patients. Among the surveyed physicians, 75% reported relevant experience in this area. Critical determinants for effective decision-making include at least 3 years of palliative care experience and specific training in protocols for palliative care and the WMV.

It is important to recognise that palliative care is still a relatively new field in Thailand since the late 1990s. A significant development occurred with the introduction of the 2007 National Health Act, which includes Section 12. This section grants individuals the right to create a living will, allowing them to refuse medical interventions solely aimed at prolonging life during the terminal stage or to decline treatments that would prolong severe suffering from illness.^[18,19] This legislation, which introduced the concept of advance directives or living wills, marked a pivotal moment in Thai healthcare. It has allowed both patients and healthcare providers to become more familiar with end-of-life decision-making, fostering greater confidence in withholding or withdrawing LSTs.

Since then, palliative care education has progressively evolved over the past decade. While it is not yet a mandatory component of the undergraduate medical curriculum, it has been increasingly incorporated into postgraduate training, particularly within family medicine residency programmes. This includes instruction on ethically complex procedures, such as the withdrawal of LSTs, including WMV. The importance of palliative care is further underscored by its formal inclusion as one of the Entrustable Professional Activities (EPAs) in the national family medicine residency curriculum.^[17,20] In addition, the launch of the Certificate of Medical Proficiency in Palliative Care in Family Medicine in 2018 marked a significant milestone in the structured training of Thai physicians. More recently, the introduction of the Diploma in the Thai Subspecialty Board of Palliative Medicine in 2024 further strengthens national efforts to professionalise and standardise advanced palliative care training. These educational advancements have enhanced the capacity of family physicians to navigate the clinical, ethical, and legal dimensions of end-of-life decision-making. The relatively young demographic of respondents in this study (mean age 34.6 years) likely reflects this emerging generation of physicians who have received more systematic exposure to palliative care principles. Many have been trained during a period in which patient autonomy and the ethical legitimacy of WMV have been more broadly emphasised and accepted. In contrast, older generations of physicians – whose training may have predated formalised palliative care curricula – may be less familiar with WMV protocols or more reluctant to initiate withdrawal, despite evolving ethical and legal support.

The most decisive factors in patient-related decision-making are a patient’s expressed refusal of mechanical ventilation, either through verbal declaration or an advance directive, coupled with the patient’s actively dying status. These observations are consistent with the Faber-Langendoen study^[7] that identified similar influential elements as recognised by critical care physicians. Such congruence emphasises the medical ethics principle of respect for patient autonomy.^[21] This perspective is also consistent with provisions in the National Health Act, which assures that healthcare providers, when acting in accordance with a living will, are exempt from legal liability.^[19] This provision significantly alleviates legal apprehensions among physicians. In the context of patients nearing the end of life, this insight strengthens the assurance in their prognosis, confirming that mechanical ventilation does not contribute to prolonging life under such circumstances.

Significant patient factors influencing decisions include irreversible cognitive or functional decline from neurodegenerative diseases, physical deterioration leading to dependence or frailty, and reduced consciousness or comatose conditions. These factors are corroborated by multiple studies.^[6,7,10] Our research also identifies terminal cancer or end-stage non-cancer diagnoses as substantial influences, likely because these conditions are generally understood to have a poor prognosis, simplifying intubation decisions due to the minimal likelihood of altering the outcome or prolonging life. Conversely, Huynh et al.^[10] did not find these conditions to be associated with treatment cessation decisions. This contrast could stem from the specific diseases Huynh examined, such as haematologic malignancies and solid tumours, which follow distinct illness trajectories^[22] and thus influence decisions differently. Non-cancer diseases, with their diversity and complexity, introduce considerable prognostic uncertainty, adding another layer of complexity to the decision-making process for WMV.

While the survey did not differentiate between malignant and non-malignant conditions, Thai family physicians routinely provide palliative care to both groups. This comprehensive scope of practice aligns with national palliative care data from 2021, which reported that patients with advanced cancer represented 50.1% of those receiving services, while non-cancer diagnoses accounted for 49.9%.^[23] These nearly equal proportions underscore the diverse caseload encountered by family physicians. Accordingly, the decision-making factors explored in this study are applicable across diagnostic categories and may be broadly relevant to terminal illnesses of various aetiologies.

Finally, while this study explored multiple decision-making domains, it did not include data on the duration of mechanical ventilation before withdrawal. Future research should examine this factor more closely, as timing may significantly influence both clinical decision-making and perceived appropriateness of withdrawal, particularly in the context of uncertain prognoses and evolving care goals.

Moreover, family physicians emphasise the importance of reaching consensus within a multidisciplinary team when determining a patient’s eligibility for treatment withdrawal, particularly in cases involving mechanical ventilation. Clear communication from the primary physician regarding the patient’s terminal status is also seen as essential to the team’s decision-making process. These collaborative practices help alleviate the emotional and ethical burden of decision-making and reduce moral distress for individual clinicians. In both hospital and community settings, family physicians play a central coordinating role in bringing together multidisciplinary team members. This includes palliative care specialists, nurses, social workers, and, where appropriate, spiritual advisors such as Buddhist monks. Their position at the intersection of medical care and community context enables them to facilitate culturally sensitive, ethically grounded, and clinically appropriate decision-making. These practices are consistent with international guidelines, which recommend team-based consultations before finalising the withdrawal of LSTs.^[24-27]

Age appears to exert only a moderate influence on decision-making processes, a conclusion that aligns with the findings of Gerstel et al.^[9] yet stands in contrast to those of Cook et al.^[6] Notably, both studies were undertaken within intensive care settings, but they reported different mean ages for participants: 72.4 years in Gerstel’s research versus 61.2 years in Cook’s investigation. This disparity underscores that age is not an isolated factor in these medical decisions. Instead, it highlights that physicians typically consider age in conjunction with other significant factors, such as the presence of comorbidities, when making critical healthcare determinations.

The active participation of family members or substitute decision-makers (SDMs) is pivotal in the decision-making process, especially when it involves consenting to the withdrawal of life support, significantly shaping the decisions of family physicians. Given that intubated patients face severe limitations in communicating their preferences and the fact that a substantial segment of the Thai population lacks familiarity with living wills^[18] – often resulting in a dearth of advance directives – the responsibility and autonomy to make critical medical decisions frequently shift to patients’ families or appointed SDMs. In light of this, Thai physicians accord significant importance to and rely heavily on the opinions expressed by patients’ families. While this practice may ostensibly stem from the collectivist cultural norms characteristic of Asian societies,^[18] our research findings resonate with those from studies undertaken in Western contexts as well,^[7,28] suggesting a universal inclination towards family involvement in healthcare decision-making. Experience in palliative care and proficiency in the withdrawal process emerged as the most influential factors in decision-making. Physicians with at least 3 years of palliative care experience were 5.30 times more likely to opt for the cessation of mechanical ventilation in terminally ill patients, while those who had received specific training in withdrawal procedures were 8.97 times more likely to make such decisions. To our knowledge, this is the first study to examine these two determinants simultaneously, making direct comparisons with other studies difficult due to the lack of prior research on this specific interplay. The variety of training formats among respondents reflects the diverse pathways through which Thai family physicians acquire palliative care competence. Short courses and distance learning programmes are commonly available and tend to emphasise ethical principles and communication skills, but often lack practical training in procedures such as WMV – meaning some physicians may not have performed it at all. Residency training offers more experiential exposure through clinical rotations, varying from 1 to 5 months depending on the institution, and may provide occasional opportunities for hands-on WMV. In contrast, palliative care fellowship training, formally recognised in 2018, includes structured procedural instruction with WMV designated as EPA Level 4. This level indicates that the learner is expected to perform the procedure independently, without supervision.

Although no specific case minimum is mandated, expert consensus suggests that fellows typically perform WMV in at least several cases, often in the range of five to ten or more. Importantly, however, the number of cases alone may not fully capture a physician’s competency, as even a few complex or ethically challenging cases can offer meaningful experiential learning.

Our study did not ascertain a pronounced influence of organisational factors on the decision-making processes related to the withdrawal of LST. However, we observed that the existence of explicit protocols or guidelines for terminating treatment in terminally ill patients has a significant bearing on these critical decisions. This correlation is in line with the findings presented by Willms and Brewer^[29] in which 72% of respiratory therapists agreed on the necessity for healthcare institutions to establish and adhere to local protocols or guidelines concerning the discontinuation of mechanical ventilation. We also discerned that the role of committees, specifically those responsible for offering insights on decisions about treatment cessation, is influential in determining the outcomes. Unfortunately, there is a noticeable dearth of research focusing solely on this variable. This research gap may be attributed to the comprehensive clinical practice guidelines prevalent in numerous countries, which already prescribe transparent methodologies for mediating disputes within clinical teams. These procedures advocate for a consensus-driven approach involving multidisciplinary teams, senior experts, and, when required, the intervention of ethics committees.^[30] Consequently, the immediate influence of such committees has not been extensively explored in academic inquiries. Nonetheless, it is imperative to highlight the apparent scarcity of ethics committees in Thai healthcare settings, a shortfall that suggests many facilities are operating without this essential oversight. This revelation emphasises the urgent need to champion the establishment of such bodies to bolster the quality of healthcare standards in Thailand.

The majority of family physicians demonstrate a positive attitude towards the WMV for terminally ill patients, while a smaller fraction displays a neutral position, and notably, there are no indications of negative attitudes. This pattern suggests a broad consensus among practitioners. It is widely accepted that discontinuing mechanical ventilation under these circumstances is ethically permissible and does not violate medical principles. However, our findings stand in contrast to studies undertaken in ICU settings^[11,31] which reveal that only approximately one-quarter of physicians concur with ceasing mechanical ventilation when it serves only to extend life without quality. This variation could stem from the distinct educational emphases of family medicine programmes, a point touched upon earlier in our discussion.

CONCLUSION

Family physicians widely agree that WMV in terminally ill patients is both ethically acceptable and consistent with medical practice standards. This decision is primarily influenced by three key factors: Active involvement of family members or SDMs, the physician’s experience and training in palliative care, and the patient’s preferences, expressed either verbally or through an advance directive. To improve practice, we advocate for the promotion of advanced care planning to prevent unnecessary intubation, the expansion of palliative care education in all residency programmes, and the development of national clinical practice guidelines to standardise and support decision-making.