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Systematic review of factors influencing decisions to limit treatment in the emergency department
  1. Nathan Walzl1,
  2. Ian A Sammy2,3,
  3. Paul M Taylor4,5,
  4. Jason E Smith6,7,
  5. David J Lowe8,9
  1. 1 Queen Elizabeth University Hospital, Glasgow, UK
  2. 2 Emergency Department, Scarborough General Hospital, Lower Scarborough, Trinidad and Tobago
  3. 3 Tobago Regional Health Authority, Lower Scarborough, Trinidad and Tobago
  4. 4 The University of Sheffield School of Health and Related Research, Sheffield, UK
  5. 5 St Luke's Hospice, Sheffield, UK
  6. 6 Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
  7. 7 Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
  8. 8 Emergency Department, Queen Elizabeth University Hospital, Glasgow, UK
  9. 9 University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK
  1. Correspondence to Dr Nathan Walzl, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK; nathan.walzl2{at}


Background Emergency physicians are frequently faced with making decisions regarding how aggressive to be in caring for critically ill patients. We aimed to identify factors that influence decisions to limit treatment in the Emergency Department (ED) through a systematic search of the available literature.

Design Prospectively registered systematic review of studies employing any methodology to investigate factors influencing decisions to limit treatment in the ED. Medline and EMBASE were searched from their inception until January 2019. Methodological quality was assessed using the Mixed Methods Appraisal Tool, but no studies were excluded based on quality. Findings were summarised by narrative analysis.

Results 10 studies published between 1998 and 2016 were identified for inclusion in this review, including seven cross-sectional studies investigating factors associated with treatment-limiting decisions, two surveys of physicians making treatment-limiting decisions and one qualitative study of physicians making treatment-limiting decisions. There was significant heterogeneity in patient groups, outcome measures, methodology and quality. Only three studies received a methodology-specific rating of ‘high quality’. Important limitations of the literature include the use of small single-centre retrospective cohorts often lacking a comparison group, and survey studies with low response rates employing closed-response questionnaires. Factors influencing treatment-limiting decisions were categorised into ‘patient and disease factors’ (age, chronic disease, functional limitation, patient and family wishes, comorbidity, quality of life, acute presenting disorder type, severity and reversibility), ‘hospital factors’ (colleague opinion, resource availability) and ‘non-patient healthcare factors’ (moral, ethical, social and cost factors).

Conclusions Several factors influence decisions to limit treatment in the ED. Many factors are objective and quantifiable, but some are subjective and open to individual interpretation. This review highlights the complexity of the subject and the need for more robust research in this field.

  • emergency department

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Handling editor Mary Dawood

  • Contributors DJL and NW conceived and designed the study. NW acquired the data. NW, DJL and IAS analysed and interpreted the data. NW drafted the manuscript and all authors contributed substantially to its revision. JES and PMT substantively reviewed and edited the manuscript. NW takes responsibility for the paper as a whole.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.