Forgoing life support in western European intensive care units: the results of an ethical questionnaire

Under what conditions is euthanasia acceptable to lay people and health professionals?

Euthanasia is legal only in the Netherlands and Belgium, but it is on occasion performed by physicians elsewhere. We recruited in France two convenience samples of 221 lay people and of 189 professionals (36 physicians, 92 nurses, 48 nurse's aides, and 13 psychologists) and asked them how acceptable it would be for a patient's physician to perform euthanasia in each of 72 scenarios. The scenarios were all combinations of three levels of the patient's life expectancy (3 days, 10 days, or 1 month), four levels of the patient's request for euthanasia (no request, unable to formulate a request because in a coma, some form of request, repeated formal requests), three of the family's attitude (do not uselessly prolong care, no opinion, try to keep the patient alive to the very end), and two of the patient's willingness to undergo organ donation (willing or not willing). We found that most lay people and health care professionals structure the factors in the patient scenarios in the same way: they assign most importance to the extent of requests for euthanasia by the patient and least importance (the lay people) or none (the health professionals) to the patient's willingness to donate organs. They also integrate the information from the different factors in the same way: the factors of patient request, patient life expectancy, and (for the lay people) organ donation are combined additively, and the family's attitude toward prolonging care interacts with patient request (playing a larger role when the patient can make no request). Thus we demonstrate a common cognitive foundation for future discussions, at the levels of both clinical care and public policy, of the conditions under which physician-performed euthanasia might be acceptable.

Outcome and ethics in severe brain damage

The patient with severe brain damage represents a considerable ethical challenge for the medical team due to uncertainties in diagnosis and prognosis, the younger age of many of these patients, and the frequent acute nature of the disease, which allows little time for discussion of end-of-life issues with the patient. Surrogates are often relied on to fill in the gaps and provide their, not always reliable, interpretation of how they feel the patient would want to have been treated. The debate regarding the withdrawing/withholding of life-sustaining treatment is discussed but may not apply to many patients with severe brain damage who do not usually require invasive life support. However, withdrawal of artificial feeding and hydration is very relevant to such patients and is highly controversial. These issues are highly emotive and subjective, and individuals' views will depend on many factors including cultural background and religion. There are relatively few published data regarding ethical issues in the severely brain damaged patient and open discussion of the multiple facets of this difficult area must be encouraged.

Evaluation of Changes in Forgoing Life-Sustaining Treatment in Israeli ICU Patients

INTRODUCTION

Over the last several years, there have been legal decisions and changes in medical directives concerning end-of-life decisions in Israel.

METHODS

The data were compared to evaluate the changes in the frequency and types of forgoing of life-sustaining treatment (FLST) in patients who were admitted to the ICU during period I (November 1994 to July 1995) and period II (January 1998 to January 1999).

RESULTS

During period I, there were 385 ICU admissions, and during period II there were 627 ICU admissions. In period I, FLST or death occurred in 13.5% of patients, and in 12% in period II. There was no significant difference in cardiopulmonary resuscitation (9% vs 13%, respectively), withholding therapy (90% vs 91%, respectively), or withdrawing therapy (0% vs 0%, respectively) between the two study periods.

CONCLUSIONS

There was no significant change in the frequency or types of FLST in an Israeli ICU between 1994 and 1998, despite passage of a new Patients' Rights Law and the issuing of a Ministry of Health directive on the treatment of the terminally ill, both of which occurred in 1996, and recent district court decisions favoring the termination of life-sustaining therapies.

Most critically ill patients are perceived to die in comfort during withdrawal of life support: a Canadian multicentre study

PURPOSE

Most deaths in intensive care units (ICUs) follow a withdrawal of life support (LS). Evaluation of this process including the related perspectives of grieving family members is integral to improvement of palliation in the ICU.

METHODS

A prospective, multicentre, cohort study in six Canadian university-affiliated ICUs included 206 ICU patients (length of stay >or=48 hr) who received mechanical ventilation (MV) before LS withdrawal. We recorded modes, sequence and time course of LS withdrawal and drug usage (4 hr before; 4-8 hr and 8-12 hr before death). We asked a specified family member to assess patient comfort and key aspects of end-of life care.

RESULTS

MV was withdrawn from 155/206 (75.2%) patients; 97/155 (62.6%) died after extubation and 58/155 (37.4%) died with an airway in place. The most frequently used drugs and the cumulative doses [median (range)] in the four hours before death were: morphine 119/206, 24 mg, (2-450 mg); midazolam 45/206, 24 mg, (2-380 mg); and lorazepam 35/206, 4 mg, (1-80 mg). These doses did not differ among the three time periods before death. Of 196 responses from family members most indicated that patients were perceived to be either totally (73, 37.2%), very (48, 24.5%), or mostly comfortable (58, 29.6%). Times to death, morphine use and family members' perceptions of comfort were similar for each type of change to MV.

CONCLUSIONS

Most patients were perceived by family members to die in comfort during a withdrawal of LS. Perceptions of patient comfort and drug use in the hours before death were not associated with the mode or sequence of withdrawal of LS, or the time to death.

Preferred plasma volume expanders for critically ill patients: results of an international survey

OBJECTIVE

Criteria for plasma volume expander selection in critically ill patients remain controversial. This study evaluated preferences of intensivists regarding plasma volume expanders.

DESIGN

International survey using a 75-item questionnaire.

PARTICIPANTS AND SETTING

All members of the European and French Societies of Intensive Care Medicine (n=2,415 in 1,610 adult ICUs in Europe and elsewhere) were invited to participate, and 577 (24%) working in 515 ICUs (32%) returned completed questionnaires.

RESULTS

Among respondents, 17% used crystalloids alone as their first-choice strategy, 18% colloids alone, and 65% both. Colloids alone were often chosen in patients with cirrhosis (42%), coagulation disorders (42%), or adult respiratory distress syndrome (39%); and crystalloids in patients with dehydration (85%), drug overdose (59%), or acute renal failure (49%). First-line plasma expanders were as follows: isotonic crystalloids (81%), starches (55%), gelatins (35%), albumin (7%), plasma (6%), dextrans (4%), and hypertonic crystalloids (2%). Colloids alone were used more frequently in the United Kingdom (40%), starches in Germany (81%) and The Netherlands (66%), and gelatins in the United Kingdom (68%). The main factors behind preferences for first-line plasma volume expanders were time to volume loss correction, duration of effect, adverse events, and cost.

CONCLUSIONS

Colloids are widely used as first-line treatment, usually in combination with crystalloids. Starches are the most widely used colloids in Europe, where albumin use is declining. However, strategies vary widely across clinical situations and countries.

Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary

OBJECTIVE

The purpose of the conference was to provide clinical practice guidance in end-of-life care in the ICU via answers to previously identified questions relating to variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of healthcare providers, the use of imprecise and insensitive terminology and incomplete documentation in the medical record.

PARTICIPANTS

Presenters and jury were selected by the sponsoring organizations (American Thoracic Society, European Respiratory Society, European Society of Intensive Care Medicine, Society of Critical Care Medicine, Société de Réanimation de Langue Française). Presenters were experts on the question they addressed. Jury members were general intensivists without special expertise in the areas considered. Experts presented in an open session to jurors and other healthcare professionals.

EVIDENCE

Experts prepared review papers on their specific topics in advance of the conference for the jury's reference in developing the consensus statement.

CONSENSUS PROCESS

Jurors heard experts' presentations over 2 days and asked questions of the experts during the open sessions. Jury deliberation with access to the review papers occurred for 2 days following the conference. A writing committee drafted the consensus statement for review by the entire jury. The 5 sponsoring organizations reviewed the document and suggested revisions to be incorporated into the final statement.

CONCLUSIONS

Strong recommendations for research to improve end-of-life care were made. The jury advocates a shared approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honor decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the team, to decide on the reasonableness of the planned action. If a conflict cannot be resolved, an ethics consultation may be helpful. The patient must be assured of a pain-free death. The jury subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double-effect" should not detract from the primary aim to ensure comfort.

Palliative care in the intensive care unit: barriers, advances, and unmet needs

The concept that critical illness and terminal illness are necessarily distinct entities has given way to the understanding that they often exist on the same spectrum. Consequently, there is growing consensus that palliative treatment must coexist with attempts at restorative treatment in the intensive care unit (ICU). Palliative care in the ICU has evolved from a relatively one-dimensional construct of terminal sedation in dying patients to a multidisciplinary field addressing symptom control, physician-patient-family communication,spiritual needs, and the needs of health care providers. As ongoing research efforts yield new insights, our ability to practice evidence-based palliative care in the ICU will grow, and new avenues for improvement will become evident.

General medicine practitioners' attitudes towards "do not attempt resuscitation" orders

OBJECTIVE

To examine whether "all-or-none" guidelines for cardiopulmonary resuscitation (CPR) are being applied by practitioners on general medical wards (GMWs).

HYPOTHESIS

Do not attempt resuscitation (DNAR) orders are rarely related to patient preferences. Limited resuscitation efforts are being practiced to circumvent the need for DNAR orders.

DESIGN

A surprise opinion survey (presented below), based on case vignette and practice description, and performed by remote control votes.

SETTING

The multi-centre forum for practitioners on GMWs within the greater Jerusalem district.

PARTICIPANTS

79/85 clinicians practicing/training on GMWs in six teaching hospitals, who attended the forum and responded within 3 min to the survey.

RESULTS

Fifty-eight practitioners (73%) assigned a DNAR order for a patient unable to express a preference and only 43 (55%) complied with the request of a competent patient for a DNAR order (P < 0.05]; 95% CI: 2-34). During the past year, only five practitioners (9% of respondents) had performed CPR solely when pathophysiological benefit was expected, 31 (59%) had performed limited CPR efforts and only 13 (28%) had discussed the subject of DNAR with patients and their next of kin >5 times.

CONCLUSIONS

(1) DNAR orders are rarely discussed with patients and their next of kin in GMWs within the region examined; (2) even when DNAR is discussed, physicians tend to confer DNAR orders based on their personal value judgements rather than on patient preferences; (3) practitioners on GMWs perform CPR when no pathophysiological benefit is expected; (4) limited resuscitation efforts are performed frequently in GMWs.

Ethics roundtable debate: child with severe brain damage and an underlying brain tumour

A young person presents with a highly malignant brain tumour with hemiparesis and limited prognosis after resection. She then suffers an iatrogenic cardiac and respiratory arrest that results in profound anoxic encephalopathy. A difference in opinion between the treatment team and the parent is based on a question of futile therapy. Opinions from five intensivists from around the world explore the differences in ethical and legal issues. A Physician-ethicist comments on the various approaches.

Clinician discomfort with life support plans for mechanically ventilated patients

OBJECTIVE

To examine the incidence and predictors of clinician discomfort with life support plans for ICU patients.

DESIGN AND SETTING

Prospective cohort in 13 medical-surgical ICUs in four countries.

PATIENTS

657 mechanically ventilated adults expected to stay in ICU at least 72 h.

MEASUREMENTS AND RESULTS

Daily we documented the life support plan for mechanical ventilation, inotropes and dialysis, and clinician comfort with these plans. If uncomfortable, clinicians stated whether the plan was too technologically intense (the provision of too many life support modalities or the provision of any modality for too long) or not intense enough, and why. At least one clinician was uncomfortable at least once for 283 (43.1%) patients, primarily because plans were too technologically intense rather than not intense enough (93.9% vs. 6.1%). Predictors of discomfort because plans were too intense were: patient age, medical admission, APACHE II score, poor prior functional status, organ dysfunction, dialysis in ICU, plan to withhold dialysis, plan to withhold mechanical ventilation, first week in the ICU, clinician, and city.

CONCLUSIONS

Clinician discomfort with life support perceived as too technologically intense is common, experienced mostly by nurses, variable across centers, and is more likely for older, severely ill medical patients, those with acute renal failure, and patients lacking plans to forgo reintubation and ventilation. Acknowledging the sources of discomfort could improve communication and decision making.

Parental role in medical decision-making: fact or fiction? A comparative study of ethical dilemmas in French and American neonatal intensive care units

Neonatal intensive care has been studied from an epidemiological, ethical, medical and even sociological perspective, but little is known about the impact of parental involvement in decision-making, especially in critical cases. We rely here on a comparative, case-based approach to study the parental role in decision-making within two technologically identical but culturally and institutionally different contexts: France and the United States. These contexts rely on two opposed models of decision-making: parental autonomy in the United States and medical paternalism in France. This paternalism model excludes parents from the decision-making process. We investigate whether parental involvement leads to different outcomes from exclusively medically determined decisions or whether "technological imperatives" outplay all other factors to shape a unique, 'medically optimal' outcome. Using empirical data generated from extensive ethnographic fieldwork, in-depth interviews with 60 clinicians and 71 parents and chart review over a year in two neonatal intensive care units (one in France and one in the US), we analyze the factors that can explain the observed differences in decision-making in medically identical cases. Parental involvement and the legal context play a less role than physicians' differential use of certainty versus uncertainty in prognosis, a conclusion that corroborates the fact that medical control over ethical dilemmas remains even in the context of autonomy. French physicians do not ask parents permission to withdraw care (as expected in a paternalistic context); but symmetrically, American neonatologists (despite the prevailing autonomy model) tend not to ask permission to continue. The study provides an analysis of the making of "ethics", with an emphasis on how decisions are conceptualized as ethical dilemmas. The final conclusion is that the ongoing medical authority on ethics remains the key issue.

Advance orders to limit therapy in 67 long-term care facilities in Finland

OBJECTIVE

To assess the documentation of a do-not-attempt-resuscitation (DNAR) or do-not-hospitalize (DNH) orders in the medical record and to determine factors related to these orders.

MATERIALS AND METHODS

Five thousand six hundred and fifty four subjects from three different levels of institutional long-term care (LTC), chronic care hospitals (n = 1989), nursing homes (n = 3310), and assisted living (n = 335) in 67 LTC facilities in 19 municipalities were assessed.

RESULTS

Out of these patients, 751 (13%) had a DNAR order and only 36 (0.6%) had a DNH order. The variation in DNAR orders between individual LTC institutions was enormous, ranging from 0 to 92%. In logistic regression analysis, individual institutions and their local caring cultures had the strongest explanatory value (R(2) = 0.49) for advance orders to limit therapy. Impaired activity in daily living (ADL) function (R(2) = 0.11), impaired cognition (R(2) = 0.07), level of LTC (R(2) = 0.05), and diagnoses (R(2) = 0.04) did not provide adequate explanations. Terminal prognosis was not significantly associated with advance orders.

CONCLUSIONS

We found marked differences in the use of DNAR and DNH orders between caring units. Diseases and ADL status were only weakly significant as background factors. Open discussions, general guidelines, and research about the adequacy of DNAR decisions are needed to improve equality and self-empowerment among the elderly residing in institutions.

Forgoing life-sustaining treatments in children: a comparison between Northern and Southern European pediatric intensive care units

OBJECTIVES

This study was conducted to determine how the decision-making process to forgo life support differs between southern and northern European pediatric intensive care units.

DESIGN

Multiple-center, prospective study.

SETTING

Thirty-nine pediatric intensive care units: 12 from northern Europe and 27 from southern Europe.

PATIENTS

All consecutive deaths were recorded over a 4-month period. Group 1 and group 2 included patients who died in northern and southern pediatric intensive care units, respectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Three hundred fifty children were enrolled, 68 in group 1 and 282 in group 2. The decision to forgo life-sustaining treatment was made in 116 children (group 1, n = 32; group 2, n = 84). In both groups, the decision was discussed by caregivers during a formal meeting. The decision to forgo life-sustaining treatment was more often made in northern countries than in southern ones (47% vs. 30%, p =.02). Parents were informed of this decision in 95% of cases in group 1 vs. 68% in group 2 (p =.01). In both groups, the final decision was made by the medical staff. Parents' contributions to the decision-making process did not differ between the two groups according to the practitioners' opinion. The decision was documented in the medical charts in 100% of the cases in group 1 and in 51% of the cases in group 2 (p =.0001).

CONCLUSIONS

The decision-making process appears to be similar between northern and southern European countries. The respective contributions of the parents and the medical staff in the final decision itself seem to be identical between northern and southern countries. However, in northern European countries, the level of parents' information about the decision-making process appears higher and the decision is more often documented in the medical chart.

Analysis of terminal events in 109 successive deaths in a Belgian intensive care unit

OBJECTIVE

To determine the incidence of end-of-life decisions in intensive care unit (ICU) patients.

DESIGN AND SETTING

Prospective data collection and questionnaire in a 31-bed medicosurgical ICU in a university hospital.

PATIENTS AND PARTICIPANTS

All 109 ICU patients who died during a 3-month period (April-June 2001). Members of the ICU team were also invited to complete a questionnaire regarding the circumstances of each patient's death. Cardiopulmonary resuscitation was performed in 21 of the patients; other mechanisms leading to death were brain death (n=19), refractory shock (n=17), and refractory hypoxemia (n=2). The decision was taken in the remaining 50 patients to withdraw (n=43) or withhold (n=7) therapy. Questionnaires were completed for 68 patients, by physician and nurse in 40 cases, physician only in 20 cases, and nurse only in 8 cases. Questionnaires were obtained for 34 of 50 patients for whom a decision was made to limit therapy.

RESULTS

Respondents generally felt that the decision was timely (n=28, 82%), 5 (15%) felt the decision was too late, and one (3%) that the decision was made too soon, before the family could be informed.

CONCLUSIONS

Therapeutic limitations are frequent in patients dying in the ICU, with withdrawing more common than withholding life support. Generally members of the ICU staff were satisfied with the end-of-life decisions made.

Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003

The jurors identified numerous problems with end of life in the ICU including variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of health-care providers, the use of imprecise and insensitive terminology, and incomplete documentation in the medical records. The jury strongly recommends that research be conducted to improve end-of-life care. The jury advocates a "shared" approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honour decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the health-care team, to decide on the reasonableness of the planned action. In the event of conflict, the ICU team may agree to continue support for a predetermined time. Most conflicts can be resolved. If the conflict persists, however, an ethics consultation may be helpful. Nurses must be involved in the process. The patient must be assured of a pain-free death. The jury of the Consensus Conference subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double effect" should not detract from the primary aim to ensure comfort.

Intensive care physicians' attitudes concerning distribution of intensive care resources. A comparison of Israeli, North American and European cohorts

OBJECTIVE

To evaluate the attitudes of Israeli intensive care physicians regarding intensive care unit (ICU) triage issues.

DESIGN

An opinion survey using questionnaires similar to those used in a previous study in the United States.

SETTING AND PARTICIPANTS

Forty-three physicians, members of the Israel Society of Critical Care Medicine (45%).

RESULTS

Important factors for admission to the last ICU bed were: small likelihood of surviving hospitalization, irreversibility of acute disorder, nature of chronic disorders and the physician's personal attitude. Most respondents would admit a patient with a predicted survival of a few weeks (70%) or a patient whose quality of life would be poor according to the physician's (98%) or patient's (77%) definition, to the last ICU bed. The personal attitude of the respondents and their own view of the patient's quality of life were considered as important as the quality of life as viewed by the patient. Israeli physicians tended to refuse patient admission into the ICU more than their US counterparts. Most Israeli physicians refused to discharge an ICU patient in order to admit another, despite bed shortage.

CONCLUSIONS

The attitudes of Israeli intensive care physicians towards distribution of ICU resources differ from those of their United States counterparts; they are more paternalistic and comply less with requests for admission. Such attitudes are comparable to those expressed by some European intensive care physicians, highlighting the existence of diversity in the factors important to physicians' decision-making.

Practices of anaesthesiologists with regard to withholding and withdrawal of life support from the critically ill in Turkey

BACKGROUND

To determine practices of Turkish anaesthesiologists with regard to withholding and withdrawal of life support from the critically ill.

METHODS

An anonymous questionnaire consisting of 18 questions was mailed to 439 members of the Turkish Society of Anaesthesiology and Reanimation.

RESULTS

Three hundred and 69 questionnaires were returned (84% response). Over 90% of the respondents indicated that they were Muslim. We found that 66% of respondents had initiated written or oral do-not-resuscitate orders, most frequently after discussion with colleagues (82%).

CONCLUSIONS

While a number of similarities were found between Turkish anaesthesiologists and those from other countries, some specific differences could be identified, particularly related to consensus decision-making and sharing information with other providers and the value of Ethics Committees in the decision-making process.

Ethical aspects in the management of the terminally ill patient in the pediatric intensive care unit

OBJECTIVE

To identify the prevalence of management plans and decision-making processes for terminal care patients in pediatric intensive care units.

METHODOLOGY

Evidence-based medicine was done by a systematic review using an electronic data base (LILACS, 1982 through 2000) and (MEDLINE, 1966 through 2000). The key words used are listed and age limits (0 to 18 years) were used.

RESULTS

One hundred and eighty two articles were found and after selection according to the exclusion/inclusion criteria and objectives 17 relevant papers were identified. The most common decisions found were do-not-resuscitation orders and withdrawal or withholding life support care. The justifications for these were "imminent death" and "unsatisfatory quality of life".

CONCLUSION

Care management was based on ethical principles aiming at improving benefits, avoiding harm, and when possible, respecting the autonomy of the terminally ill patient.

Intensive care admission decisions for a patient with limited survival prospects: a questionnaire and database analysis

OBJECTIVE

To explore the concept of futility by asking clinicians for estimates of survival and admission decisions for an intensive care unit patient with little chance of survival, and to compare these estimates with results from an intensive care database.

DESIGN

Questionnaire based on the presenting features of a genuine patient. It asked for estimated hospital survival, decision on intensive care admission, resuscitation status and importance of family views. Analysis of a regional intensive care database.

SETTING

Physicians working in British intensive care units.

PARTICIPANTS

We received 169 replies, 146 from consultants.

MEASUREMENTS AND RESULTS

Median estimated hospital survival was 5%; 60% of consultants and 76% of trainees would have admitted the patient, with 9% and 14%, respectively, prepared to perform further cardiopulmonary resuscitation. Among those estimating survival probability as less than 1%, 17.2% would have admitted the patient. Family opinions were vital to 4.3% of respondents and unimportant to 9.8%. There were 251 patients in the database with similar physiological derangements. Their observed hospital mortality was 91%. At intensive care admission an admitting physician assessed 111 of these patients as 'expected to die'. Mortality in this group was 99.1% (one survivor).

CONCLUSIONS

Experienced intensivists did not agree on estimated survival. Even when estimates agreed, admission decisions varied. Database analysis suggested that clinical judgement is relevant when assessing the risk of dying. Lack of consensus on survival estimates and admission decisions suggests that it would be difficult to achieve agreement on appropriate use of intensive care resources and on what constitutes futile treatment.

Autonomy gone awry: a cross-cultural study of parents' experiences in neonatal intensive care units

This paper examines parents' experiences of medical decision-making and coping with having a critically ill baby in the Neonatal Intensive Care Unit (NICU) from a cross-cultural perspective (France vs. U.S.A.). Though parents' experiences in the NICU were very similar despite cultural and institutional differences, each system addresses their needs in a different way. Interviews with parents show that French parents expressed overall higher satisfaction with the care of their babies and were better able to cope with the loss of their child than American parents. Central to the French parents' perception of autonomy and their sense of satisfaction were the strong doctor-patient relationship, the emphasis on medical certainty in prognosis versus uncertainty in the American context, and the "sentimental work" provided by the team. The American setting, characterized by respect for parental autonomy, did not necessarily translate into full parental involvement in decision-making, and it limited the rapport between doctors and parents to the extent of parental isolation. This empirical comparative approach fosters a much-needed critique of philosophical principles by underscoring, from the parents' perspective, the lack of "emotional work" involved in the practice of autonomy in the American unit compared to the paternalistic European context. Beyond theoretical and ethical arguments, we must reconsider the practice of autonomy in particularly stressful situations by providing more specific means to cope, translating the impersonal language of "rights" and decision-making into trusting, caring relationships, and sharing the responsibility for making tragic choices.

Controversial issues in critical care for the elderly: a perspective from Canada

Age alone does not at all preclude the possibility of warranted, effective, and successful intensive care. From a medical perspective, the key issue is the reversibility or otherwise of an acute illness and where this illness sits in the trajectory of that individual's life and possible death. It makes no more sense to admit a 19-year-old let alone a 91-year-old to an intensive care unit if intensive care cannot provide what is needed. Of paramount importance in our consideration of critical care for the elderly is a determination and an understanding of the many needs--medical, emotional, social, spiritual, psychologic--that elderly people have. By exploring them with compassion and sensitivity, we can establish whether the goals of care include critical care and the associated technology, or whether alternative and more conservative approaches more closely reflect the values and preferences of an increasingly elderly population.

Intensive care outflow limitationfrequency, etiology, and impact

OBJECTIVE

To assess the frequency, causes, and effect of unsuccessful discharge decisions from the ICU.

SETTING

An 11-bed general intensive care unit of a 750-bed urban university hospital, tertiary referral center and level one trauma center.

DESIGN

A prospective, observational study.

PATIENTS

All ICU patients judged appropriate for discharge by the ICU attending physician.

MEASUREMENTS AND RESULTS

A total of 856 attempted discharges in 706 patients were analyzed over 16 months. Of these, 703 (82%) were successful within 24 hours. Of the remaining 153 unsuccessful discharges, 51 (33%) were deferred because of medical deterioration, 32 (21%) at the request of the ward physicians or nurses and 70 (46%) because of administrative difficulties (lack of ward bed space or disagreement over admitting service). When compared to patients successfully discharged on the first attempt, those whose discharge was deferred had a significantly longer ICU admission prior to the first discharge attempt (median 4d v 3d, P =.009), and a higher proportion required intermediate care (48% v 26%, P <.001). Both these factors were independently associated with unsuccessful discharge in a logistic regression analysis (OR 1.04, 95%CI 1.02, 1.06, P =.0001, OR 2.05 95%CI 1.30, 3.26, P =.002, respectively). Deferred discharges accounted for 153 days of ICU care (2.6% of the total) and were associated with ICU overflow on 118 days (2% of all ICU days).

CONCLUSION

ICU outflow limitation occurs in up to 1 in 6 discharges. It can be due to medical deterioration, level of care issues or administrative problems, and may lead to inefficient use of ICU resources.

Life-sustaining treatment decisions in Portuguese intensive care units: a national survey of intensive care physicians

Introduction

The objective of the present study was to evaluate the opinion of Portuguese intensive care physicians regarding 'do-not-resuscitate' (DNR) orders and decisions to withhold/withdraw treatment.

Methods

A questionnaire was sent to all physicians working on a full-time basis in all intensive care units (ICUs) registered with the Portuguese Intensive Care Society.

Results

A total of 266 questionnaires were sent and 175 (66%) were returned. Physicians from 79% of the ICUs participated. All participants stated that DNR orders are applied in their units, and 98.3% stated that decisions to withhold treatment and 95.4% stated that decisions to withdraw treatment are also applied. About three quarters indicated that only the medical group makes these decisions. Fewer than 15% of the responders stated that they involve nurses, 9% involve patients and fewer than 11% involve patients' relatives in end-of-life decisions. Physicians with more than 10 years of clinical experience more frequently indicated that they involve nurses in these decisions (P < 0.05), and agnostic/atheist doctors more frequently involve patients' relatives in decisions to withhold/withdraw treatment (P < 0.05). When asked about who they thought should be involved, more than 26% indicated nurses, more than 35% indicated the patient and more than 25% indicated patients' relatives. More experienced doctors more frequently felt that nurses should be involved (P < 0.05), and male doctors more frequently stated that patients' relatives should be involved in DNR orders (P < 0.05). When a decision to withdraw treatment is made, 76.8% of 151 respondents indicated that they would initiate palliative care; no respondent indicated that they would administer drugs to accelerate the expected outcome.

Conclusion

The probability of survival from the acute episode and patients' wishes were the most important criteria influencing end-of-life decisions. These decisions are made only by the medical group in most of the responding ICUs, with little input from nursing staff, patients, or patients' relatives, although many respondents expressed a wish to involve them more in this process. Sex, experience and religious beliefs of the respondents influences the way in which these decisions are made.

Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit

BACKGROUND

In critically ill patients who are receiving mechanical ventilation, the factors associated with physicians' decisions to withdraw ventilation in anticipation of death are unclear. The objective of this study was to examine the clinical determinants that were associated with the withdrawal of mechanical ventilation.

METHODS

We studied adults who were receiving mechanical ventilation in 15 intensive care units, recording base-line physiological characteristics, daily Multiple Organ Dysfunction Scores, the patient's decision-making ability, the type of life support administered, the use of do-not-resuscitate orders, the physician's prediction of the patient's status, and the physician's perceptions of the patient's preferences about the use of life support. We examined the relation between these factors and withdrawal of mechanical ventilation, using Cox proportional-hazards regression analysis.

RESULTS

Of 851 patients who were receiving mechanical ventilation, 539 (63.3 percent) were successfully weaned, 146 (17.2 percent) died while receiving mechanical ventilation, and 166 (19.5 percent) had mechanical ventilation withdrawn. The need for inotropes or vasopressors was associated with withdrawal of the ventilator (hazard ratio, 1.78; 95 percent confidence interval, 1.20 to 2.66; P=0.004), as were the physician's prediction that the patient's likelihood of survival in the intensive care unit was less than 10 percent (hazard ratio, 3.49; 95 percent confidence interval, 1.39 to 8.79; P=0.002), the physician's prediction that future cognitive function would be severely impaired (hazard ratio, 2.51; 95 percent confidence interval, 1.28 to 4.94; P=0.04), and the physician's perception that the patient did not want life support used (hazard ratio, 4.19; 95 percent confidence interval, 2.57 to 6.81; P<0.001).

CONCLUSIONS

Rather than age or the severity of the illness and organ dysfunction, the strongest determinants of the withdrawal of ventilation in critically ill patients were the physician's perception that the patient preferred not to use life support, the physician's predictions of a low likelihood of survival in the intensive care unit and a high likelihood of poor cognitive function, and the use of inotropes or vasopressors.

End-of-life decision-making in six European countries: descriptive study

BACKGROUND

Empirical data about end-of-life decision-making practices are scarce. We aimed to investigate frequency and characteristics of end-of-life decision-making practices in six European countries: Belgium, Denmark, Italy, the Netherlands, Sweden, and Switzerland.

METHODS

In all participating countries, deaths reported to death registries were stratified for cause (apart from in Switzerland), and samples were drawn from every stratum. Reporting doctors received a mailed questionnaire about the medical decision-making that had preceded the death of the patient. The data-collection procedure precluded identification of any of the doctors or patients. All deaths arose between June, 2001, and February, 2002. We weighted data to correct for stratification and to make results representative for all deaths: results were presented as weighted percentages.

FINDINGS

The questionnaire response rate was 75% for the Netherlands, 67% for Switzerland, 62% for Denmark, 61% for Sweden, 59% for Belgium, and 44% for Italy. Total number of deaths studied was 20480. Death happened suddenly and unexpectedly in about a third of cases in all countries. The proportion of deaths that were preceded by any end-of-life decision ranged between 23% (Italy) and 51% (Switzerland). Administration of drugs with the explicit intention of hastening death varied between countries: about 1% or less in Denmark, Italy, Sweden, and Switzerland, 1.82% in Belgium, and 3.40% in the Netherlands. Large variations were recorded in the extent to which decisions were discussed with patients, relatives, and other caregivers.

INTERPRETATION

Medical end-of-life decisions frequently precede dying in all participating countries. Patients and relatives are generally involved in decision-making in countries in which the frequency of making these decisions is high.

End-of-life decisions in Swedish ICUs. How do physicians from the admitting department reason?

OBJECTIVE

To study how physicians from the admitting department reason during the decision-making process to forego life-sustaining treatment of patients in intensive care units (ICUs).

DESIGN

Qualitative interview that applies a phenomenological approach.

SETTING

Two ICUs at one secondary and one tertiary referral hospital in Sweden.

PARTICIPANTS

Seventeen admitting-department physicians who have participated in decisions to forego life-sustaining treatment.

RESULTS

The decision-making process as it appeared from the physicians' experiences was complex, and different approaches to the process were observed. A pattern of five phases in the process emerged in the interviews. The physicians described the process principally as a medical one, with few ethical reflections. Decision-making was mostly done in collaboration with other physicians. Patients, family and nurses did not seem to play a significant role in the process.

CONCLUSION

This study describes how physicians reasoned when confronted with real patient situations in which decisions to forego life-sustaining treatment were mainly based on medical--not ethical--considerations.

End-of-life intensive care unit decisions, communication, and documentation: an evaluation of physician training

PURPOSE

The majority of patients dying in intensive care units (ICUs) do so after the forgoing of life-sustaining therapies (FLST). Communication between physicians, patients, and their families regarding the decision to FLST has not been evaluated in Israel.

MATERIALS AND METHODS

All patients who had FLST in a general ICU were enrolled in the study. We evaluated whether physicians communicated and documented the FLST decisions with patients or the patients' families. We also assessed the effect of the physician's geographic place of training on communication behavior.

RESULTS

Over a period of 8.5 months, 385 patients were admitted to a general ICU in Israel. Fifty-seven patients died or had FLST. Twelve of these 57 were excluded from the study. Thus, 45 (79%) patients had FLST and were enrolled in the study. All patients were deemed medically incompetent to make FLST decisions. In 24 (53%) patients, FLST was discussed with the family before the decision to forgo therapy. Discussion occurred later with 6 other families, who were unavailable at the time the FLST decision was made. In 15 patients, there were no discussions with families. American-trained physicians discussed FLST with 22 of 29 families initially and 5 other families later (93%), whereas the Eastern European-trained physicians discussed FLST with only 3 of 16 (19%) families (P <.001). Documentation of FLST was present in 26 (90%) patients of American-trained physicians and 8 (50%) patients of Eastern European-trained physicians (P <.001).

CONCLUSIONS

FLST is common in an Israeli ICU. Patients are not medically competent to make FLST decisions. American-trained physicians discuss and document FLST more often than Eastern European-trained physicians.

Ethics and decision making in end stage lung disease

Most physicians believe they do more good than harm, and these duties of helping and not harming the patient are rooted in the Hippocratic oath, the good Samaritan tradition, and the Order of the Knight Hospitallers founded in the 11th century to care for pilgrims and those wounded in the Crusades.(1) In recent times the simple principles of beneficence and non-maleficence have been augmented and sometimes challenged by a rising awareness of patient/consumer rights, and the public expectation of greater involvement in medical, social and scientific affairs which affect them. In a publicly funded healthcare system in which rationing (explicit or otherwise) is inevitable, the additional concepts of utility and distributive justice can easily come into conflict with the individual's right to autonomy. Possible treatment options for end stage lung disease include transplantation and long term invasive ventilation which are challenging in resource terms. Other interventions such as pulmonary rehabilitation and palliative care are relatively low cost but not uniformly accessible.

Attitudes of health care workers towards waking a terminally ill patient in the intensive care unit for treatment decisions

OBJECTIVE

We examined whether health care workers would wake an intubated patient whose preferences are not known, and whether attitudes are influenced by how health care workers themselves would like to be treated if they were in the patient's place.

DESIGN, SETTING, AND SUBJECTS

Convenience sample of 90 participants at a postgraduate lecture to anesthesiologists and related professions. Participants filled out questionnaires after a case presentation followed by two commentaries, one arguing against, the other for waking a 49-year-old intubated patient suffering from a large, intratracheal, poorly differentiated metastatic squamous cell carcinoma of the lungs. The patient was not aware of the diagnosis and poor prognosis and had not expressed any preferences.

RESULTS

Participants were almost equally divided between the two alternatives. Significant differences were found between professions concerning the willingness not to wake the patient (19.8% of nurses vs. 45% of physicians and others). There was a strong correlation between the preferences of the health care worker for her-/himself and what he/she would do if in charge of the patient.

CONCLUSIONS

Our study shows that attitudes of health care workers towards waking and informing an intubated patient in the intensive care unit about a hopeless situation differ. Educational programs should ensure that physicians and nurses, especially when discussing and deciding withdrawal of vital support, are aware of theses differences and realize that their own behavior can be influenced by their own preferences if themselves in the patient's situation.

On what are our end-of-life decisions based?

BACKGROUND

The incidence of withholding and withdrawing life support from the critically ill has increased in recent years. The aim of this study was to assess the degree of consistency between the weight assigned by intensivists to different determinants and their relation to end-of-life decisions, and to evaluate the current concepts in withholding or withdrawing intensive care in Nordic countries.

METHODS

Forty-one intensivists from Nordic countries completed a questionnaire sent by e-mail: consistency between contributing factors and the decisions regarding 10 actual cases was evaluated by logistic regression analysis and by the classification (leave-one-out) method. Concepts in management after the withdrawal decision were also analyzed.

RESULTS

The median (range) number of withdrawals per physician was four (range 0-10) out of 10 cases. No single factor was an independent covariant of all decisions made. The classification method revealed that approximately 70% only of decisions could be predicted correctly. Different actions taken after a decision to withdraw intensive care varied from 9.8% (discontinuing ventilator therapy) to 97.6% (informing relatives).

CONCLUSIONS

No generally accepted grounds for end-of-life decisions could be detected among Nordic intensivists. In addition, the current concept of management after decision to withdraw therapy varies markedly. This study has implications in further assessment of the individual decision-making process and the uniformity of actions after withdrawal decisions.

Multicenter clinical research in adult critical care

OBJECTIVE

To describe the development, organization, and operation of several collaborative groups conducting investigator-initiated multicenter clinical research in adult critical care.

DESIGN

To review the process by which investigator-initiated critical care clinical research groups were created using examples from Europe, Australia, the United States, and Canada. Various models of group structure and function are discussed, highlighting complementary approaches to protocol development, multicenter study management, and project funding.

DATA SOURCES

Published peer review research and unpublished terms of reference documents on the structure and function of these groups.

DATA SYNTHESIS

The overall goal of clinical critical care research groups engaged in multicenter studies is to improve patient outcomes through conducting large, rigorous investigations. Research programs we reviewed included the following: a) multicenter epidemiologic studies and surveys; b) technology evaluations of mechanical ventilation; c) investigations focused on three priority fields (acute lung injury, infection, and acute brain injury); d) a series of randomized trials of treatments for one syndrome (acute respiratory distress syndrome); and e) diverse methodologies addressing several clinical problems. The structure and function of these research groups differ according to their historical development, research culture, and enabling resources. Specific protocols emerge from clinical questions generated by investigators or from collectively prioritized research agendas. Project funding includes government support, peer-review grants, intensive care foundations, industry, local hospital funds, and hybrid models. Infrastructure for study management varies widely.

CONCLUSIONS

Several national and international groups have engaged in investigator-initiated multicenter critical care research. The development, organization, and operational methods of these groups illustrate several collaborative models for clinical investigations in the intensive care unit. Common characteristics of these groups are a cohesive spirit, a sense of mission to achieve shared research goals, and acknowledgment that such an organization is much more than the sum of its parts.

Cancer patients' perceptions of do not resuscitate orders

Patients' perceptions of do not resuscitate (DNR) orders and how and when to present the information were sought to aid in framing DNR policy. Semi-structured interviews of 23 patients being treated for cancer, were conducted by a clinical psychologist. The interviews were transcribed and analysed with the aid of a qualitative software package. Discourse analysis enabled hypotheses to be formed based on consistencies and variations of the language used. Most patients understood what DNR meant and preferred DNR orders to 'good palliative care' orders. They saw it as their autonomous right and responsibility to make such decisions. They would seek information on the likely medical outcomes of resuscitation but also would use non-rational criteria based on emotional and social factors to make their decisions. Family considerations suggest that personal autonomy is not the overriding basis of the decision. Patients were unsure of the best timing of a DNR discussion and were prepared to defer to doctors' intuition. Most advocated written DNR orders but few had them. Families were construed as advocates but also seen as constraining individual autonomy. When considering DNR orders, patients recognise the diversity of preferences likely to exist that belie a one policy fits all approach.

Barriers to optimum end-of-life care for minority patients

Although major efforts are underway to improve end-of-life care, there is growing evidence that improvements are not being experienced by those at particularly high risk for inadequate care: minority patients. Ethnic disparities in access to end-of-life care have been found that reflect disparities in access to many other kinds of care. Additional barriers to optimum end-of-life care for minority patients include insensitivity to cultural differences in attitudes toward death and end-of-life care and understandable mistrust of the healthcare system due to the history of racism in medicine. These barriers can be categorized as institutional, cultural, and individual. Efforts to better understand and remove each type of barrier are needed. Such efforts should include quality assurance programs to better assess inequalities in access to end-of-life care, political action to address inadequate health insurance and access to medical school for minorities, and undergraduate and continuing medical education in cultural sensitivity.

French intensivists do not apply American recommendations regarding decisions to forgo life-sustaining therapy

OBJECTIVE

Recommendations for making and implementing decisions to forgo life-sustaining therapy in intensive care units have been developed in the United States, but the extent that they are realized in practice has yet to be measured.

DESIGN

Prospective, multicenter, 4-wk study. For each patient with an implemented decision to forgo life-sustaining therapy, the deliberation and decision implementation procedures were recorded.

SETTING

French intensive care units.

PATIENTS

All consecutive patients admitted to 26 French intensive care units.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 1,009 patients admitted, 208 died in the intensive care unit. A decision to forgo life-sustaining therapy was implemented in 105 patients. The number of supportive treatments forgone was 2.3 +/- 1.7 per patient. Decisions to forgo sustaining therapy were preceded by 3.5 +/- 2.5 deliberation sessions. Proxies were informed of the deliberations in 62 (59.1%) cases but participated in only 18 (17.1%) decisions. The patient's perception of his or her quality of life was rarely evaluated (11.5%), and only rarely did the decision involve evaluating the patient's wishes (7.6%), the patient's religious values (7.6%), or the cost of treatment (7.6%). Factors most frequently evaluated were medical team advice (95.3%), predicted reversibility of acute disease (90.5%), underlying disease severity (83.9%), and the patient's quality of life as evaluated by caregivers (80.1%).

CONCLUSIONS

A decision to withhold or withdraw life-sustaining therapy was implemented for half the patients who died in the French intensive care units studied. In many cases, the decision was taken without regard for one or more factors identified as relevant in U.S. guidelines.

Forgoing life-sustaining treatments: how the decision is made in French pediatric intensive care units

OBJECTIVES

The decision to forgo life support is frequently made in pediatric intensive care units (PICUs). A group of experts is currently preparing recommendations for guidelines concerning this decision-making process in France. We have performed a prospective study to help the experts. This study documents how children die in French PICUs and how the decision to limit life support is made.

DESIGN

A multicenter, prospective, cross-sectional study.

SETTING

Thirty-three multidisciplinary PICUs in university hospitals.

PATIENTS

All consecutive deaths were recorded over a 4-month period. Children who died after a medical decision to forgo life-sustaining treatment were included in group 1 and children who died from other causes were included in group 1.

MAIN RESULTS

A total of 264 consecutive children died, 40.1% from group 1 and 59.8% from group 2. Patients of both groups were primarily admitted for acute respiratory failure (group 1, 50.8%; group 2, 52.6%). Neurologic emergencies were more frequent in patients in group 1, whereas patients with cardiovascular failures were more frequent in group 2. When there was a question of whether to pursue life-sustaining treatment, the parents' opinions were recorded in 72.1% of cases. A specific meeting was called to make this decision in 80.1% of cases. This meeting involved the medical staff in all cases. Parents were aware of the meeting in 10.7% of cases. The conclusion of the meeting was reported to the parents in 18.7% of cases and documented in the patient's medical record in 16% of cases. Experts who were not members of the PICU staff were invited to give their opinion in 62.2% of cases.

CONCLUSIONS

The decision to forgo life-sustaining treatment is frequently made for children dying in French PICUs. Guidelines must be available to help the medical staff reach this decision. Knowledge of the decision-making process in French PICUs provides the experts with information needed to elaborate such recommendations.

To resuscitate or not: a dilemma in terminal cancer care

One of the difficult dilemmas in terminal care is the decision on whether to start or withhold cardiopulmonary resuscitation (CPR). Is this decision made on purely medical grounds, or is it also influenced by the physician's personal characteristics or education? The aim of this study was to look at factors affecting this decision. A questionnaire was sent out to a stratified sample of 1180 Finnish doctors. The response rate was 62%. The physicians were asked whether they would (a) start CPR or (b) withhold CPR in a scenario describing the unexpected death of a young terminal cancer patient. Data were also collected on demographics, post-graduate training, experience of terminal care, general life values and attitudes, and experiences of severe illness in the family. The proportion of surgeons, internists, GPs and oncologists who said they would have started CPR was 16, 10, 19 and 14%, respectively. Among physicians aged under 35 years, from 35 to 49 years and over 49 years, the proportions of physicians choosing active CPR were 29, 14 and 13%, respectively (P<0.001). As for those with personal experience of terminal care, 13% indicated they would have started CPR compared with 23% of those who had no experience (P<0.01). Those who made a decision in favour of CPR showed a significantly (P<0.001) more negative attitude to withdrawing life-sustaining treatment and valued length of life to a much greater extent (P<0.01).

Cultural differences in end-of-life care

The exact time of death for many intensive care unit patients is increasingly preceded by an end-of-life decision. Such decisions are fraught with ethical, religious, moral, cultural, and legal difficulties. Key questions surrounding this issue include the difference between withholding and withdrawing, when to withhold/withdraw, who should be involved in the decision-making process, what are the relevant legal precedents, etc. Cultural variations in attitude to such issues are perhaps expected between continents, but key differences also exist on a more local basis, for example, among the countries of Europe. Physicians need to be aware of the potential cultural differences in the attitudes not only of their colleagues, but also of their patients and families. Open discussion of these issues and some change in our attitude toward life and death are needed to enable such patients to have a pain-free, dignified death.

Evaluating our end-of-life practice

Ferrand et al's recent study of withholding and withdrawing life support in intensive care units in France reminds us that reporting end-of-life practices is an important step towards enhancing end-of-life care. The study highlights differences between the paternalistic approach to decision making in Europe, and the patient autonomy model in the USA. However, the reasons intensivists report for withholding or withdrawing life support are similar in both cultures. Intensivists in France make decisions despite a lack of formal guidelines in their country. This study should serve as a stimulus for educating the public and motivating more groups to monitor their end-of-life practices.