Doctors support end-of-life practices but feel legally exposed, study finds

A large majority of Maltese doctors support end-of-life practices – such as ‘do not resuscitate’ orders and the withholding or withdrawal of treatment – but more than half report feeling insufficiently protected from a medico-legal standpoint.

The findings come from a study titled ‘Maltese Doctors and Their Views on End-of-Life Issues’ by Jurgen Abela, published in the Malta Medical Journal.

The research highlights the need for a coordinated approach to address existing policy and legal gaps, particularly through frameworks that are flexible enough to be applied in varied healthcare settings including hospitals, primary care, geriatric facilities and care homes.

The study emphasises that addressing these issues should be a national priority. It suggests that the Malta Medical Council could play a key role in developing and endorsing such frameworks, allowing doctors to approach end-of-life care with greater confidence and security.

The study involved an online questionnaire distributed to doctors working at Mater Dei Hospital, Gozo General Hospital, Mount Carmel Hospital, Primary HealthCare, St Vincent De Paule Hospital, Karin Grech Hospital, Sir Anthony Mamo Oncology Centre, the Association of Private Family Doctors, and the Malta Association of Public Health Medicine.

The questionnaires were sent in 2022 and 2023 – before the government launched the public consultation on the introduction of euthanasia earlier this year. The consultation period has closed, and the government is now reviewing the feedback to the proposal that centres around the availability of voluntary assisted euthanasia for terminally ill patients with less than six months to live.

Legally exposed

A total of 195 doctors responded to the questionnaire.  A non-responder analysis confirmed that the sample was representative of the broader medical population.

The findings revealed that 160 doctors (82%) identified as Roman Catholic, and 148 doctors (80%) stated that their personal philosophy of life played an important or very important role in end-of-life decisions.

Doctors were asked about a variety of end-of-life practices, including do-not-resuscitate (DNR) orders, the withdrawal and withholding of treatment (WDWH), intensifying analgesia under the doctrine of double effect (a principle used to justify providing pain relief even if it may hasten death), and advance care planning (ACP).

Support for DNR orders was very high at 98%, yet 60% of respondents said they did not feel legally protected in enacting them. In the case of withdrawing or withholding treatment, 95% agreed with the practice, but 66% reported feeling legally unsafe.

For the doctrine of double effect, 89% agreed in principle, while 66% again felt legally exposed. ACP was supported by 94% of doctors, but 62% still expressed concern over legal protection.

Palliative sedation, the monitored use of medication to induce unconsciousness to relieve severe suffering, was supported by 93.3% of respondents. The study noted that this strong support suggests doctors are willing to use all available tools to reduce patient distress.

More training needed

A significant majority of doctors – 73%, or 143 respondents – admitted they would benefit from further training in this area. The most frequently mentioned areas where training was needed included communication with patients and their families, pain and symptom management, and navigating ethical dilemmas.

The research identified a key contradiction: although doctors support end-of-life practices, many feel unsafe in applying them. One possible explanation lies in the slow pace at which the legal system has adapted to these realities.

However, the study cautions against relying solely on legal reform. Legal processes are often cumbersome, rigid, and ill-suited to the dynamic and personal nature of end-of-life care.

Over-legalisation could undermine the doctor-patient relationship, which is central to good medical practice in such sensitive situations. Instead, the study advocates for a model rooted in clear and compassionate communication with patients.

However, the study cautions against relying solely on legal reform. Legal processes are often cumbersome, rigid, and ill-suited to the dynamic and personal nature of end-of-life care

An individualised approach – rather than a legalistic one focused on formal documents like living wills – should guide end-of-life care.

Policymakers must also recognise that patients exist beyond secondary care settings.

Many are treated in the community, private hospitals, care homes and geriatric institutions. Therefore, information about end-of-life decisions needs to be effectively shared among all professionals involved in a patient’s care.

Ultimately, paperwork and form-filling should never replace timely and meaningful conversations.

A national strategy that embraces this philosophy, while also addressing the legal uncertainties and training gaps faced by doctors, is urgently needed, the study said.