purpose: The purpose of this study was to determine the impact of external factors on physicians' life-support decisions. "External factors" are those factors that promote the interests of people other than the patient. Examples of external factors include physician legal liability and family wishes about patient care. subjects and methods: A nationwide sample consisted of 300 randomly selected physician-members from the American Society of Law and Medicine (ASLM) and 300 from the Society for Critical Care Medicine (SCCM); 179 ASLM physicians (60%) and 165 SCCM physicians (55%) responded. A mailed questionnaire presented three cases, each requiring the physician to make a life-support decision. For each case, the physician chose one of several life-support options and rated the importance to his or her decision of specific "decision factors," including some external factors. We assumed the physician would choose the management option supported by the decision factors that the physician considered most important. For this reason, we used discriminant analysis to identify the factors whose importance ratings best predicted management choices. results: In the first case, 46% of ASLM respondents and 55% of SCCM respondents chose to stop the ventilator of a chronically comatose patient with unknown preferences about life support. Thirty-one percent of ASLM and 27% of SCCM respondents chose to continue the ventilator, and 21% of ASLM and 14% of SCCM respondents chose to apply for a judicial decision. Importance ratings for the external factor, physician legal liability, best predicted management choices. In the second case, 95% of ASLM and 94% of SCCM respondents chose to resuscitate a cancer patient at the patient's request; 3% of ASLM and 4% of SCCM respondents chose no resuscitation. Importance ratings for preferences best predicted management choices. In the third case, 38% of ASLM and 35% of SCCM respondents honored a stroke patient's previous refusal of tube feedings, but 59% of ASLM and 62% of SCCM respondents authorized tube feedings in order to secure nursing home placement. Importance ratings for patient preferences best predicted management choices in this cse. External factors impacted management choices considerably in the first case and more modestly in the second and third cases. conclusion: External factors impact the life-support decisions of physicians. Physician legal liability may have an especially great impact on these decisions when patients' preferences are not known.
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