Ethical aspects of limiting end-of-Life treatment of adult patients at the primary healthcare level in family and emergency medicine: a systematic review

Background: Decisions to limit treatment near the end of life are challenging and common in primary healthcare, especially in family and emergency medicine. Objectives: This review aimed to [1] examine the evidence on the decision-making process regarding treatment limitation in end-of-life care in family and emergency medicine [2], identify associated ethical considerations, and [3] compare the evidence between family and emergency medicine. Methods: A systematic search of PubMed and Embase was conducted for studies published between 2004 and 2024. Eligible studies focused on ethical aspects of limiting treatment in end-of-life care in family and emergency medicine, such as decision-making processes, influencing factors, and ethical considerations. Quality was assessed using adapted Critical Appraisal Skills Programme checklists. Results: Of the 477 identified studies, 12 met the inclusion criteria. Eight papers reported research on treatment limitations in emergency medical care, two in family/general medicine, one on medication discontinuation in end-of-life care, and one on goals-of-care conversations in emergency departments. Patients, families and colleagues were involved to varying degrees. Family physicians were rarely included in emergency care decisions, despite their potential to align care with patient preferences. Decision-making in emergency medicine was characterized by rapid, protocol-driven processes, often constrained by time and workload, while decisions in family medicine relied on longitudinal patient relationships and clinical judgment, though lacking formalized guidelines. Key factors influencing decisions on limiting treatment included patient and family wishes and values, illness severity, prognosis, previous functional limitation, age, poor predicted quality of life and cultural and religious contexts. Conclusion: Our review showed that decisions regarding treatment limitations in primary care settings remain underexplored, particularly in family medicine. More research and development of clearer guidelines, as well as enhanced collaboration between family and emergency physicians, could improve primary end-of-life care.