Beyond the binary: a nationwide study of physician decision orientations toward artificial hydration in terminal...

Artificial hydration (AH) in terminally ill cancer patients remains ethically and clinically controversial. Although evidence suggests limited benefit near the end of life, AH is frequently administered, particularly in East Asian settings where it may carry symbolic meaning. This study conceptualized physician decision-making as a clinical spectrum and examined demographic, clinical, and ethical factors associated with AH decision orientations.

A nationwide cross-sectional survey of palliative care-trained physicians in Taiwan assessed clinical practices and ethical domains (autonomy, beneficence, non-maleficence, justice, cultural, and emotional factors). Scenario-based scores were used to derive continuation, withdrawal, and variability indices. Two-step cluster analysis identified decision-orientation profiles. Group differences were analyzed using ANOVA, chi-square tests, and multinomial logistic regression.

Among 377 respondents, 4 decision-orientation clusters emerged: contextual/proportional, selective continuation, conservative/continuation-leaning balancing, and consistent withdrawal. Several demographic and professional characteristics differed across clusters. Ethical domains also differed significantly. Multinomial regression showed that cultural and emotional factors were associated with contextual/proportional orientation, whereas beneficence independently predicted selective continuation orientation. Hydration volume and consideration of life expectancy differed across clusters, supporting behavioral distinctions among decision orientations.

AH decision-making reflects multiple context-sensitive physician orientations shaped by both ethical considerations and professional characteristics, rather than a binary continuation-withdrawal model.