End-of-life decisions in Burn Intensive Care Units - An International Survey

Do not resuscitate orders and limitation of therapeutic effort: Ethical challenges in healthcare teams in Chile

The purpose of this paper is to delve into the ethical aspects experienced by the healthcare team when they receive the directive to limit therapeutic effort or a do-not-resuscitate order. From an interpretative, qualitative paradigm with a content analysis approach, a process based on three phases was conducted: pre-analysis in which categories were identified, the projection of the analysis, and inductive analysis. During 2023, interviews were conducted in the clinical setting of a high-complexity hospital in Chile with 56 members of the healthcare teams from critical and emergency units, from which four categories emerged: a) the risk of violating patients' rights by using do-not-resuscitate orders and limiting therapeutic effort; b) the gap in the interpretation of the legal framework addressing the care and attention of patients at the end of life or with terminal illnesses by the healthcare team; c) ethical conflicts in end-of-life care; and d) efficient care versus holistic care in patients with terminal illness. There are significant gaps in bioethics training and aspects of a good death in healthcare teams facing the directive to limit therapeutic effort and not resuscitate. It is suggested to train personnel and work on a consensus guide to address the ethical aspects of a good death.

The Complex Dynamics of Decision-Making at the End of Life in the Intensive Care Unit: A Systematic Review of Stakeholders' Views and Influential Factors

A lack of consensus resulting in severe conflicts is often observed between the stakeholders regarding their respective roles in end-of-life (EOL) decision-making in the ICU. Since the burden of these decisions lies upon the individuals, their opinions must be known by medical, judicial, legislative, and governmental authorities. Part of the solution to the issues that arise would be to examine and understand the views of the people in different societies. Hence, in this systematic review, we assessed the attitudes of the physicians, nurses, families, and the general public toward who should be involved in decision-making and influencing factors. Toward this, we searched three electronic databases, i.e., PubMed, CINAHL (Cumulative Index to Nursing & Allied Health), and Embase. A matrix was developed, discussed, accepted, and used for data extraction by two independent investigators. Study quality was evaluated using the Newcastle-Ottawa Scale. Data were extracted by one researcher and double-checked by a second one, and any discrepancies were discussed with a third researcher. The data were analyzed descriptively and synthesized according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-three studies met our inclusion criteria. Most involved healthcare professionals and reported geographic variations in different timeframes. While paternalistic features have been observed, physicians overall showed an inclination toward collaborative decision-making. Correspondingly, the nursing staff, families, and the public are aligned toward patient and relatives' participation, with nurses expressing their own involvement as well. Six categories of influencing factors were identified, with high-impact factors, including demographics, fear of litigation, and regulation-related ones. Findings delineate three key points. Firstly, overall stakeholders' perspectives toward EOL decision-making in the ICU seem to be leaning toward a more collaborative decision-making direction. Secondly, to reduce conflicts and reach a consensus, multifaceted efforts are needed by both healthcare professionals and governmental/regulatory authorities. Finally, due to the multifactorial complexity of the subject, directly related to demographic and regulatory factors, these efforts should be more extensively sought at a regional level.

Components, Models of Integration, and Outcomes Associated with Palliative/ end-of-Life Care Interventions in the Burn Unit: A Scoping Review

Objective: To scope the literature to ascertain the components of palliative care (PC) interventions for burn patients, models of integration, and outcomes. Methods: Arksey and O'Malley scoping review design with narrative synthesis was employed and reported following the PRISMA-ScR guidelines. Primary studies reporting PC interventions in the burn unit were considered for inclusion. CINAHL via EBSCO, PubMed, EMBASE via OVID, Web of Science, and gray literature sources were searched from inception to June 2021. Results: Fifteen studies emerging from high-income settings were retained. Data were organized around three concepts: components of palliative/ end of life care in the burn unit; models of integration; and outcomes. The components of interventions based on the Robert Wood Johnson Foundation Critical Care End-of Life Group domains include decision-making, communication, symptom management and comfort care, spiritual support, and emotional and practical support for families. Consultative and integrative models were noted to be the strategies for integrating PC in the burn unit. The outcomes were varied with only few studies reporting healthcare staff related outcomes. Conclusion: PC may have the potential of improving end-of-life care in the burn unit albeit the limited studies and lack of standardized outcomes makes it difficult to draw stronger conclusions regarding what is likely to work best in the burn unit.

Managing the elephant in the room: responding to COVID-19's impact on data collection

BACKGROUND

The global COVID-19 pandemic has affected data collection for many researchers, in particular research that involves face-to-face interviews.

AIM

To share learning about the challenges encountered when face-to-face interviews could not continue as planned in a study and how to adapt data collection so that it can continue despite severe disruption.

DISCUSSION

This article examines the considerations and actions taken by the authors to ensure the continuity of data collection. The research aimed to use narrative inquiry to understand the experiences of significant others supporting people in intensive care units with severe burn injuries. But the pandemic meant the researchers could not meet face-to-face with participants as originally intended and so they had to consider new ways to approach data collection. The authors explore the process of adapting the interviews to video conferencing and telephone use while preserving the study's person-centred focus to remain coherent with narrative methodology.

CONCLUSION

Adapting data collection is valuable in ensuring the continuity of research. Careful consideration and planning are required to ensure the research remains robust and ethically sound.

IMPLICATIONS FOR PRACTICE

Adapting data collection methods can allow for greater flexibility when participants cannot attend face-to-face interviews.

Exploring clinicians' decision-making processes about end-of-life care after burns: A qualitative interview study

INTRODUCTION

Little is known about treatment decision-making experiences and how/why particular attitudes exist amongst specialist burn clinicians when faced with patients with potentially non-survivable burn injuries. This exploratory qualitative study aimed to understand clinicians' decision-making processes regarding end-of-life (EoL) care after a severe and potentially non-survivable burn injury.

METHODS

Eleven clinicians experienced in EoL decision-making were interviewed via telephone or video conferencing in June-August 2021. A thematic analysis was undertaken using a framework approach.

RESULTS

Decision-making about initiating EoL care was described as complex and multifactorial. On occasions when people presented with 'unsurvivable' injuries, decision-making was clear. Most clinicians used a multidisciplinary team approach to initiate EoL; variations existed on which professions were included in the decision-making process. Many clinicians reported using protocols or guidelines that could be personalised to each patient. The use of pathways/protocols might explain why clinicians did not report routine involvement of palliative care clinicians in EoL discussions.

CONCLUSION

The process of EoL decision-making for a patient with a potentially non-survivable burn injury was layered, complex, and tailored. Processes and approaches varied, although most used protocols to guide EoL decisions. Despite the reported complexity of EoL decision-making, palliative care teams were rarely involved or consulted.

What do we know about experiencing end-of-life in burn intensive care units? A scoping review

OBJECTIVES

The aim of this article is to review and synthesize the evidence on end-of-life in burn intensive care units.

METHODS

Systematic scoping review: Preferred Reporting Items for Systemic Reviews extension for Scoping Reviews was used as a reporting guideline. Searches were performed in 3 databases, with no time restriction and up to September 2021.

RESULTS

A total of 16,287 documents were identified; 18 were selected for analysis and synthesis. Three key themes emerged: (i) characteristics of the end-of-life in burn intensive care units, including end-of-life decisions, decision-making processes, causes, and trajectories of death; (ii) symptom control at the end-of-life in burn intensive care units focusing on patients' comfort; and (iii) concepts, models, and designs of the care provided to burned patients at the end-of-life, mainly care approaches, provision of care, and palliative care.

SIGNIFICANCE OF RESULTS

End-of-life care is a major step in the care provided to critically ill burned patients. Dying and death in burn intensive care units are often preceded by end-of-life decisions, namely forgoing treatment and do-not-attempt to resuscitate. Different dying trajectories were described, suggesting the possibility to develop further studies to identify triggers for palliative care referral. Symptom control was not described in detail. Palliative care was rarely involved in end-of-life care for these patients. This review highlights the need for early and high-quality palliative and end-of-life care in the trajectories of critically ill burned patients, leading to an improved perception of end-of-life in burn intensive care units. Further research is needed to study the best way to provide optimal end-of-life care and foster integrated palliative care in burn intensive care units.

Burn Care Specialists' Views Towards End of Life Decision-Making in Patients with Severe Burn Injury: Findings from an Online Survey in Australia and New Zealand

Burn care clinicians are required to make critical decisions regarding the withholding and withdrawal of treatment in patients with severe and potentially non-survivable burn injuries. Little is known about how Australian and New Zealand burn care specialists approach decision-making for these patients. This study aimed to understand clinician beliefs, values, considerations, and difficulties regarding palliative and end of life care (EoL) discussions and decision-making following severe burn injury in Australian and New Zealand burn services. An online collected respondent and institutional demographic data, as well as information about training and involvement in palliative care/EoL decision-making discussions from nurses, surgeons, and intensivists in Australian and New Zealand hospitals with specialist burn services. Twenty-nine burns nurses, 26 burns surgeons, and 15 intensivists completed the survey. Respondents were predominantly female (64%) and had a median 15 years of experience in treating burn patients. All respondents received little training in EoL decision-making during their undergraduate education; intensivists reported receiving more on-the-job training. Specialist clinicians differed on who they felt should contribute to EoL discussions. Ninety percent of respondents reported injury severity as a key factor in their decision-making to withhold or withdraw treatment, but less than half reported considering age in their decision-making. Approximately two-thirds indicated a high probability of death or a poor predicted quality of life influenced their decision-making. The three cohorts of clinicians had similar views towards certain aspects of EoL decision-making. Qualitative research could provide detailed insights into the varying perspectives held by clinicians.

Early Palliative Care Consultation in the Burn Unit: A Quality Improvement Initiative to Increase Utilization

Despite significant morbidity and mortality for major burns, palliative care consultation (PCC) is underutilized in this population. The purpose of this study is to examine the impact of a protocol using recommended "triggers" for PCC at a single academic burn center. This is a retrospective review of patient deaths over a four-year period. Use of life-sustaining treatments, comfort care (de-escalation of one or more life-sustaining treatments) and do not attempt resuscitation (DNAR) orders were determined. Use of PCC was compared during periods before and after a protocol establishing recommended triggers for early (<72 hrs of admission) PCC was instituted in 2019. A total of 33 patient deaths were reviewed. Most patients were male (n=28, 85%) and median age was 62 years [IQR 42-72]. Median revised Baux score was 112 [IQR 81-133]. Many patients had life-sustaining interventions such as intubation, dialysis, or cardiopulmonary resuscitation, often prior to admission. Amongst patients who survived >24 hrs, 67% (n=14/21) had PCC. Frequency of PCC increased after protocol development, with 100% vs. 36% of these patients having PCC before death (p=0.004). However, even during the later period, less than half of patients had early PCC despite meeting criteria at admission. In conclusion, initiation of life-sustaining measures in severely injured burn patients occurs prior to or early during hospitalization. Thus, value-based early goals of care discussions are valuable to prevent interventions that do not align with patient values and assist with de-escalation of life-sustaining treatment. In this small sample, we found that while there was increasing use of PCC overall after developing a protocol of recommended triggers for consultation, many patients who met criteria at admission did not receive early PCC. Further research is needed to elucidate reasons why providers may be resistant to PCC.

The experiences of 'significant others' supporting people with severe burn injury: An integrative literature review

BACKGROUND

Severe burn injury is a traumatic experience for both patients and their significant others. Although research has focused on the experience of people with burn injury, there is a paucity of research focusing on the experiences of the significant other. Significant others are frequently expected to advocate and make decisions on behalf of the patient, which may have an impact on their psychological wellbeing. An understanding of the experiences of significant others will inform strategies to better support their needs.

OBJECTIVES

The aim of this integrative literature review was to critically examine research related to the experiences of significant others supporting a patient with a severe burn injury in the hospital.

METHODS

CINAHL Plus with Full Text (EBSCO), MEDLINE ALL (Ovid), Scopus, and APA PsycINFO were searched up to December 2019 for English language studies using search terms burns, significant other, ICU, and psychological impact. Records were independently screened and assessed for methodological quality, and the data were synthesised.

RESULTS

Nine articles were included in the review. Three used a quantitative approach, and six were qualitative studies. Three major themes were identified, namely, (i) psychological consequences and emotional trauma, (ii) redefining relationships, and (iii) coping strategies.

CONCLUSION

The review identified that significant others experience adverse psychological consequences including post-traumatic stress, anxiety, and depression. The burn injury resulted in a redefining of relationships with others and particularly with the patient through this shared experience. Significant others found ways to adapt to stressors, including taking control of the situation and seeking greater involvement in the patient's care.

Exploring The Background, Context And Stressors Of Caregiving To Elderly Burned Patients: A Qualitative Inquiry

Elderly persons are at risk of experiencing burns and require support from both formal and informal caregivers. Informal caregiving in this situation has been minimally explored. Guided by the Stress Process Model, this study aimed at exploring the background, context, and stressors of informal caregivers of elderly burned persons during hospitalisation. A qualitative descriptive design was utilised. Purposive sampling approach was used to recruit fourteen (14) informal caregivers who rendered care to elderly burned persons during hospitalisation. Interviews were conducted and transcribed verbatim following which directed content analysis was undertaken deductively. Three categories and six sub-categories emerged which characterise the background, context, and stressors of informal caregiving to elderly burn patients. All the injuries occurred in the home setting and its sudden nature led to varied post-burn emotional responses which characterised the context of burns caregiving. Primary stressors that emerged were related to the injury, actual caregiving demand, and concerns regarding increasing frailty levels. Secondary stressors identified were financial concerns and lifestyle changes. The findings suggest that the occurrence of burn injury served as a precursor to post-burn stress response among informal caregivers. Increasing frailty levels, adequacy of household safety measures and financial issues were key concerns which emphasise the need for psychosocial/ transitional support, innovative healthcare financing measures and continuing education on burns prevention in the home setting.

Palliation, end-of-life care and burns; concepts, decision-making and communication - A narrative review

Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. Palliative care may be started because of futility, on request of the patient, or because of limited resources. The SPIKES acronym is a useful guide to avoid errors in communication with terminal patients and their relatives.

Bioethical Decisions in Neonatal Intensive Care: Neonatologists' Self-Reported Practices in Greek NICUs

This study presents, for the first time, empirical data on practices regarding bioethical decision-making in treatment of preterm and ill newborns in Greece. The aim of the study was to: (a) record self-reported practices and involvement of Greek physicians in decisions of withholding and withdrawing neonatal intensive care, and (b) explore the implication of cultural, ethical, and professional parameters in decision-making. Methods: 71 physicians, employed fulltime in all public Neonatal Intensive Care Units (NICUs) (n = 17) in Greece, completed an anonymous questionnaire between May 2009 and May 2011. Results: One-third of the physicians in our sample admitted that they have, at least once in the past, decided the limitation of intensive care of a newborn close to death (37.7%) and/or a newborn with unfavorable neurological prognosis (30.8%). The higher the physicians’ support towards the value of quality of human life, the more probable it was that they had taken a decision to withhold or withdraw neonatal intensive care (p < 0.05). Conclusions: Our research shows that Greek NICU physicians report considerably lower levels of ethical decision-making regarding preterm and ill newborns compared to their counterparts in other European countries. Clinical practices and attitudes towards ethical decision-making appear to be influenced mainly by the Greek physicians’ values.

The Role of Palliative Care in Burns: A Scoping Review

CONTEXT

Patients with severe burns may face distressing symptoms with a high risk of mortality as a result of their injury. The role of palliative care in burns management remains unclear.

OBJECTIVE

To appraise the literature on the role of palliative care in burns management.

METHODS

We used scoping review with searches in 12 databases from their inception to August 2019. The citation retrieval and retention are reported in a PRISMA statement.

FINDINGS

39 papers comprising of 30 primary studies (26 from high-income and four from middle-income countries), four reviews, two editorials, two guidelines, and one expert board review document were retained in the review. Palliative care is used synonymously with comfort and end-of-life care in burns literature. Comfort care is mostly initiated when active treatment is withheld (early deaths) or withdrawn (late deaths), limiting its overall benefits to burn patients, their families, and health care professionals. Futility decisions are usually complex and challenging, particularly for patients in the late death category, and it is unclear if these decisions result in timely commencement of comfort care measures. Three comfort care pathways were identified, but it remained unclear how these pathways evaluated "good death" or supported the family which creates the need for the development of other evidence-based guidelines.

CONCLUSION

Palliative care is applicable in burns management, but its current role is mostly confined to the end-of-life period, suggesting that it is not been fully integrated in the management process. Evidence-based guidelines are needed to support the integration and delivery of palliative care in the burn patient population.

Do patients, families, and healthcare teams benefit from the integration of palliative care in burn intensive care units? Results from a systematic review with narrative synthesis

BACKGROUND

Burn units are intensive care facilities specialized in the treatment of patients with severe burns. As burn injuries have a major impact in physical, psychosocial, and spiritual health, palliative care can be a strengthening component of integrated care.

AIM

To review and appraise the existing evidence about the integration of palliative care in burn intensive care units with respect to (1) the concept, model and design and (2) the benefits and outcomes of this integration.

DESIGN

A systematic review was conducted following PRISMA guidelines. Protocol registered with PROSPERO (CRD42018111676).

DATA SOURCES

Five electronic databases were searched (PubMed/NLM, Web of Science, MEDLINE/TR, Ovid, and CINAHL/EBSCO) until May 2019. A narrative synthesis of the findings was constructed. Hawker et al.'s tool was used for quality appraisal.

RESULTS

A total of 299 articles were identified, of which five were included for analysis involving a total of 7353 individuals. Findings suggest that there may be benefits from integrating palliative care in burn units, specifically in terms of patients' comfort, decision-making processes, and family care. Multidisciplinary teams may experience lower levels of burden as result of integrating palliative care in burn units.

CONCLUSION

This review reflects the challenging setting of burn intensive care units. Evidence from these articles suggests that the integration of palliative care in burn intensive care units improves patients' comfort, decision-making process, and family care. Further research is needed to better understand how the integration of palliative care in burn intensive care units may be fostered and to identify the outcomes of this integration.

Predictors of withdrawal of life support after burn injury

INTRODUCTION

Discussions regarding withdrawal of life support after burn injury are challenging and complex. Often, providers may facilitate this discussion when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Few papers have evaluated withdrawal of life support in burn patients. We therefore sought to determine the predictor of withdrawal of life support (WLS) in a regional burn center.

METHODS

We conducted a retrospective analysis of all burn patients from 2002 to 2012. Patient characteristics included age, gender, burn mechanism, percentage total body surface area (%TBSA) burned, presence of inhalation injury, hospital length of stay, and pre-existing comorbidities. Patients <17years of age and patients with unknown disposition were excluded. Patients were categorized into three cohorts: Alive till discharge (Alive), death by withdrawal of life support (WLS), or death despite ongoing life support (DLS). DLS patients were then excluded from the study population. Multivariate logistic regression was used to estimate predictors of WLS.

RESULTS

8,371 patients were included for analysis: 8134 Alive, 237 WLS. Females had an increased odd of WLS compared to males (OR 2.03, 95% CI 1.18-3.48; p=0.010). Based on higher CCI, patients with pre-existing comorbidities had an increased odd of WLS (OR 1.28, 95% CI 1.08-1.52; p=0.005). There was a significantly increased odds for WLS (OR 1.09, 95% CI 1.06-1.12; p<0.001) with increasing age. Similarly, there was an increased odd for WLS (OR 1.08, 95% CI 1.07-1.51; p<0.001) with increasing %TBSA. An increased odd of WLS (OR 2.47, 95% CI 1.05-5.78; p=0.038) was also found in patients with inhalation injury.

CONCLUSION

The decision to withdraw life support is a complex and difficult decision. Our current understanding of predictors of withdrawal of life support suggests that they mirror those factors which increase a patient's risk of mortality. Further research is needed to fully explore end-of-life decision making in regards to burn patients. The role of patient's sex, particularly women, in WLS decision making needs to be further explored.

Who decides in withdrawal of treatment in a critical care setting? A case study on ethical dilemma

Case description

Withdrawal of treatment is a common practice in critical care settings, perticularly when treatment is considered futile. The case study demonstrates an ethical dilemma, in which Danny is unlikely to make a functional recovery because of multiple organ dysfunction syndromes. Under such a circumstance, withdrawal of treatment will inevitably be considered, although his family refused to do so. Consequently, acritical question must be answered: Who should make the decision?

Ethical dilemma identification

Danny decided to withdraw the use of life-support, whilst his wife and adult children refused to do so. The ethical dilemma is illustrated by the following question: Who decides the withdrawal of treatment in a critical care setting?

Analysis

To provide an opotional solution to this case and make the best moral decision, the current study will critically discuss this issue in conjunction with ethical principles, philosophical theories and the values statement of the European and Chinese nurses’ codes of ethics. Additionally, the associated literature relative to this case are analysed before the decision-making.

Ethical decision-making

The best ethical decision is Danny can decide whether to withhold or withdraw life-sustaining treatment. If his family is involved in the discussion, the medical staff should balance the ethical principles when they make the decision and allocate reasonable resources for patients.

Results

In Danny’s case, health professionals opted to respect his decision to withdraw treatment. The medical staff maintained an effective communication with the family involved, and provided the appropriate intervention to collaborate with other health care professionals to perfect further care.

A few realistic questions raised by organ retrieval in the intensive care unit

Organ transplantation saves the lives of many persons who would otherwise die from end-stage organ disease. The increasing demand for donated organs has led to a renewed interest in donation after circulatory determination of death (CDD). In many countries (including France), terminally ill patients who die of circulatory arrest after a planned withdrawal of life support may be considered as organ donors under certain conditions. While having equal responsibility towards the potential donor and the persons awaiting a transplant, caregivers may experience an ethical dilemma between the responsibility to deliver the best care to the dying, and the need to retrieve the organs. Once it has been established that the patient wishes to be a donor, we assume that end-of-life care and organ donation may have convergent goals when they contribute to transforming a comfortable death into a chance of life for others in need.

Ethics in the Setting of Burned Patients

This article considers multiple ethical principles in the context of patients with burns. It explores the application of these principles to burn care and the impact on medical decision making, through several clinical vignettes.

End-of-life decisions in surgical intensive care medicine - the relevance of blood transfusions

BACKGROUND

End-of-life decisions (EOLDs) are common in the intensive care unit (ICU). EOLDs underlie a dynamic process and limitation of ICU-therapies is often done sequentially. Questionnaire-based and observational studies on medical ICUs and in palliative care reveal blood transfusions as the first therapy physicians withhold as an EOLD.

METHODS

To test whether this practice also applies to surgical ICU-patients, in an observational study, all deceased patients (n = 303) admitted to an academic surgical ICU in a three-year period were analyzed for the process of limiting ICU-therapies.

RESULTS

Restriction of further surgery (85.4%) and limiting doses of vasopressors (75.8%) were the most frequent forms of limitations in surgical ICU therapies. Surgical patients, who had blood transfusions withheld (44.6%), had more ICU-therapies withheld or withdrawn simultaneously than patients who had transfusions maintained (5 ± 2 vs. 2 ± 1, p < 0.001). Secondary EOLDs and subsequent limitations occurred less frequently in patients who had transfusions withheld with their first EOLD (17.1% vs. 35.6%, p < 0.05).

CONCLUSION

Limitation orders for blood transfusions are not a prioritized decision in EOLDs of surgical ICU patients. Withholding blood transfusions correlates with discontinuation of further significant life-support therapies. This suggests that EOLDs to withhold blood transfusions are part of the most advanced limitations of therapy on the surgical ICU.

Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units

Background

In France, decisions to limit treatment fall under the Leonetti law adopted in 2005. Leading figures from the French world of politics, science, and justice recently claimed for amendments to the law, considering it incomplete. This study, conducted before any legislative change, aimed to investigate the procedural aspects of withholding/withdrawing treatment in French ICUs and their adequacy with the existing law.

Methods

The characteristics of patients qualified for a withholding/withdrawal procedure were prospectively collected in 43 French ICUs. The study period (60 or 90 days under normal operating conditions) took place in the first half of 2013.

Results

During the study period, 777 (14 %) of 5589 admitted patients and 584 (52 %) of 1132 patients dying in the ICU had their treatment withheld or withdrawn. Whereas 344 patients had treatment(s) withheld (i.e., not started or not increased if already engaged), 433 had one or more treatment(s) withdrawn. Withdrawal of treatment was applied in 156 of 223 (70 %) brain-injured patients, compared to 277 of 554 (50 %) patients with other reasons for admission (p < 0.01). At the time of the decision-making, the patient’s wishes were known in 181 (23 %) of the 777 cases in one or more different way(s): 73 (9.4 %) from the patient, 10 (1.3 %) by advance directives, 10 (1.3 %) through a designated trusted person, and 108 (13.9 %) reported by the family or close relatives. An external consultant was involved in less than half of all decisions (356 of 777, 46 %). Of the 777 patients qualified for a withholding/withdrawal procedure, 133 (17 %) were discharged alive from the hospital (126 after withholding, 7 after withdrawal).

Conclusions

More than half of deaths in the study population occurred after a decision to withhold or withdraw treatment. Among patients under withholding/withdrawal procedures, brain-injured subjects were more likely to undergo a withdrawal procedure. The prevalence of advance directives and designated trusted persons was low. Because patients’ preferences were unknown in more than three quarters of cases, decisions remained primarily based on medical judgment. Limitations, especially withholding of treatment, did not preclude survival and hospital discharge.