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Internists' Attitudes Regarding Ethical Obligations

Marian O. Hodges, MD, MPH; Susan W. Tolle, MD; Carol Stocking, PhD; Christine K. Cassel, MD

Arch Intern Med. 1994;154(9):1013-1020.

Abstract
Background
Little is known about the attitudes of internists regarding their ethical obligation to provide or withhold tube feeding in three clinical contexts when patient preferences are not known: acute pneumonia, severe dementia, and persistent vegetative state.

Methods
A written questionnaire with patient scenarios was mailed to a randomized national sample of 1000 internist members of the American College of Physicians.

Results
Response was received from 58% of our sample (n=581). Only physicians with personal experience with tube feeding decisions were included in the subsequent analysis (n=326). Respondents were mostly male board-certified internists active in patient care in urban/suburban settings. Physicians demonstrated a predominant attitude for each scenario: 98% favored initiation of tube feeding for the patient with acute pneumonia; 84% opposed initiation of tube feeding for the patient with advanced dementia when depicted with a mixed happy/sad affect; and 80% favored withdrawal of tube feeding for the patient with established persistent vegetative state. Sixteen percent (n=51) described tube feeding as basic humane care, whereas 84% (n=265) believed tube feeding is medical therapy. Physicians were more opposed to tube feeding in certain patient scenarios than the literature suggests occurs in actual practice.

Conclusions
Our data suggest that when patient wishes are not known, physician decisions regarding tube feeding are strongly influenced by prognosis. State legislation that categorizes tube feedings differently from other medical treatments conflicts with the judgment of the majority of internist respondents.

(Arch Intern Med. 1994;154:1013-1020)

Author Affiliations
From the Robert Wood Johnson Clinical Scholars Program, University of Washington, Seattle (Dr Hodges); the Center for Ethics in Health Care and the Division of General Internal Medicine, Oregon Health Sciences University, Portland (Dr Tolle); and the Center for Clinical Medical Ethics (Dr Stocking) and the Section of General Internal Medicine (Dr Cassel), The University of Chicago, Ill. Dr Hodges is now with the Department of Medical Education, Providence Medical Center, and with the Center for Ethics in Health Care and the Division of General Internal Medicine, Oregon Health Sciences University, Portland.

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