End-of-Life Decision Making in the ICU

Social Determinants of Health and Limitation of Life-Sustaining Therapy in Neurocritical Care: A CHoRUS Pilot Project

BACKGROUND

Social determinants of health (SDOH) have been linked to neurocritical care outcomes. We sought to examine the extent to which SDOH explain differences in decisions regarding life-sustaining therapy, a key outcome determinant. We specifically investigated the association of a patient's home geography, individual-level SDOH, and neighborhood-level SDOH with subsequent early limitation of life-sustaining therapy (eLLST) and early withdrawal of life-sustaining therapy (eWLST), adjusting for admission severity.

METHODS

We developed unique methods within the Bridge to Artificial Intelligence for Clinical Care (Bridge2AI for Clinical Care) Collaborative Hospital Repository Uniting Standards for Equitable Artificial Intelligence (CHoRUS) program to extract individual-level SDOH from electronic health records and neighborhood-level SDOH from privacy-preserving geomapping. We piloted these methods to a 7 years retrospective cohort of consecutive neuroscience intensive care unit admissions (2016-2022) at two large academic medical centers within an eastern Massachusetts health care system, examining associations between home census tract and subsequent occurrence of eLLST and eWLST. We matched contextual neighborhood-level SDOH information to each census tract using public data sets, quantifying Social Vulnerability Index overall scores and subscores. We examined the association of individual-level SDOH and neighborhood-level SDOH with subsequent eLLST and eWLST through geographic, logistic, and machine learning models, adjusting for admission severity using admission Glasgow Coma Scale scores and disorders of consciousness grades.

RESULTS

Among 20,660 neuroscience intensive care unit admissions (18,780 unique patients), eLLST and eWLST varied geographically and were independently associated with individual-level SDOH and neighborhood-level SDOH across diagnoses. Individual-level SDOH factors (age, marital status, and race) were strongly associated with eLLST, predicting eLLST more strongly than admission severity. Individual-level SDOH were more strongly predictive of eLLST than neighborhood-level SDOH.

CONCLUSIONS

Across diagnoses, eLLST varied by home geography and was predicted by individual-level SDOH and neighborhood-level SDOH more so than by admission severity. Structured shared decision-making tools may therefore represent tools for health equity. Additionally, these findings provide a major warning: prognostic and artificial intelligence models seeking to predict outcomes such as mortality or emergence from disorders of consciousness may be encoded with self-fulfilling biases of geography and demographics.

Ethical evaluation in acute stroke decision-making

RATIONALE

The evidentiary standards and epistemic models of clinical care, especially those of evidence-based medicine, are dissimilar to those used in philosophy and examination of how the two systems intersect may help clinicians make more informed treatment decisions.

AIMS AND OBJECTIVES

This paper examines the use of ethical frameworks in routine clinical decision-making, using the example of acute stroke treatment decisions to demonstrate that ethical evaluation is integral to clinical practice.

METHOD

Utilising acute stroke care as a lens through which to examine the phenomenon of ethical evaluation in medical practice, we offer a philosophical analysis of the presence of ethical evaluation in medicine.

RESULTS AND CONCLUSION

We find that the medical establishment should embrace ethical evaluation as intrinsic to medical practice and that medical training and treatment guidelines should reflect this reality. Patients deserve clarity and transparency about how physicians make determinations about their treatment, and physicians should be prepared to offer explanations for those decisions.

Variability in the perception of palliative care and end-of-life care among hematology professionals from the same reference center in Bahia, Brazil: A descriptive cross-sectional study

BACKGROUND

There are several illness-specific cultural and system-based barriers to palliative care (PC) integration and end-of-life (EOL) care in the field of oncohematology.

OBJECTIVES

This study aimed to investigate the variability in the perceptions of PC and EOL care.

DESIGN AND SETTING

A cross-sectional study was conducted in the Hematology Division of our University Hospital in Salvador, Bahia, Brazil.

METHODS

Twenty physicians responded to a sociodemographic questionnaire and an adaptation of clinical questionnaires used in previous studies from October to December 2022.

RESULTS

The median age of the participants was 44 years, 80% of the participants identified as female, and 75% were hematologists. Participants faced a hypothetical scenario involving the treatment of a 65-year-old female with a poor prognosis acute myeloid leukemia refractory to first-line treatment. Sixty percent of the participants chose to follow other chemotherapy regimens, whereas 40% opted for PC. Next, participants considered case salvage for the patient who developed septic shock following chemotherapy and were prompted to choose their most probable conduct, and the conduct they thought would be better for the patient. Even though participants were from the same center, we found a divergence from the most probable conduct among 40% of the participants, which was due to personal convictions, legal aspects, and other physicians' reactions.

CONCLUSIONS

We found considerable differences in the perception of PC and EOL care among professionals, despite following the same protocols. The study also demonstrated variations between healthcare professionals' beliefs and practices and persistent historical tendencies to prioritize aggressive interventions.

At the end: A vignette-based investigation of strategies for managing end-of-life decisions in the intensive care unit

BACKGROUND

Decision-making on end-of-life is an inevitable, yet highly complex, aspect of intensive care decision-making. End-of-life decisions can be challenging both in terms of clinical judgement and social interaction with families, and these two processes often become intertwined. This is especially apparent at times when clinicians are required to seek the views of surrogate decision makers (i.e., family members) when considering palliative care.

METHODS

Using a vignette-based interview methodology, we explored how interactions with family members influence end-of-life decisions by intensive care unit clinicians (n = 24), and identified strategies for reaching consensus with families during this highly emotional phase of care.

RESULTS

We found that the enactment of end-of-life decisions were reported as being affected by a form of loss aversion, whereby concerns over the consequences of not reaching a consensus with families weighed heavily in the minds of clinicians. Fear of conflict with families tended to arise from anticipated unrealistic family expectations of care, family normalization of patient incapacity, and belief systems that prohibit end-of-life decision-making.

CONCLUSIONS

To support decision makers in reaching consensus, various strategies for effective, coherent, and targeted communication (e.g., on patient deterioration and limits of clinical treatment) were suggested as ways to effectively consult with families on end-of-life decision-making.

Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting

BACKGROUND

There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient's wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions.

METHODS

Case report and discussion of the associated ethical issues.

RESULTS

We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team.

CONCLUSION

It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.

Decision-making regarding withdrawal of life-sustaining treatment and the role of intensivists in the intensive care unit: a single-center study

Background

This study examined the experience of withholding or withdrawing life-sustaining treatment in patients hospitalized in the intensive care units (ICUs) of a tertiary care center. It also considers the role that intensivists play in the decision-making process regarding the withdrawal of life-sustaining treatment.

Methods

We retrospectively analyzed the medical records of 227 patients who decided to withhold or withdraw life-sustaining treatment while hospitalized at Ewha Womans University Medical Center Mokdong between April 9 and December 31, 2018.

Results

The 227 hospitalized patients included in the analysis withheld or withdrew from life-sustaining treatment. The department in which life-sustaining treatment was withheld or withdrawn most frequently was hemato-oncology (26.4%). Among these patients, the most common diagnosis was gastrointestinal tract cancer (29.1%). A majority of patients (64.3%) chose not to receive any life-sustaining treatment. Of the 80 patients in the ICU, intensivists participated in the decision to withhold or withdraw life-sustaining treatment in 34 cases. There were higher proportions of treatment withdrawal and ICU-to-ward transfers among the cases in whom intensivists participated in decision making compared to those cases in whom intensivists did not participate (50.0% vs. 4.3% and 52.9% vs. 19.6%, respectively).

Conclusions

Through their participation in end-of-life discussions, intensivists can help patients’ families to make decisions about withholding or withdrawing life-sustaining treatment and possibly avoiding futile treatments for these patients.

Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool

Background

Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU).

Objectives

To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates.

Methods

Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups.

Results

Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner.

Conclusions

The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians’ behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.

Palliative care for patients with HIV/AIDS admitted to intensive care units

Objective

To describe the characteristics of patients with HIV/AIDS and to compare the therapeutic interventions and end-of-life care before and after evaluation by the palliative care team.

Methods

This retrospective cohort study included all patients with HIV/AIDS admitted to the intensive care unit of the Instituto de Infectologia Emílio Ribas who were evaluated by a palliative care team between January 2006 and December 2012.

Results

Of the 109 patients evaluated, 89% acquired opportunistic infections, 70% had CD4 counts lower than 100 cells/mm³, and only 19% adhered to treatment. The overall mortality rate was 88%. Among patients predicted with a terminally ill (68%), the use of highly active antiretroviral therapy decreased from 50.0% to 23.1% (p = 0.02), the use of antibiotics decreased from 100% to 63.6% (p < 0.001), the use of vasoactive drugs decreased from 62.1% to 37.8% (p = 0.009), the use of renal replacement therapy decreased from 34.8% to 23.0% (p < 0.0001), and the number of blood product transfusions decreased from 74.2% to 19.7% (p < 0.0001). Meetings with the family were held in 48 cases, and 23% of the terminally ill patients were discharged from the intensive care unit.

Conclusion

Palliative care was required in patients with severe illnesses and high mortality. The number of potentially inappropriate interventions in terminally ill patients monitored by the palliative care team significantly decreased, and 26% of the patients were discharged from the intensive care unit.

The care of dying people in nursing homes and intensive care units: a qualitative mixed-methods study

Background

In England and Wales the two most likely places of death are hospitals (52%) and nursing homes (22%). The Department of Health published its National End of Life Care Strategy in July 2008 (Department of Health.End of Life Care Strategy: Promoting High Quality Care For All Adults at the End of Life. London: Department of Health; 2008) to improve the provision of care, recommending the use of the Liverpool Care Pathway for the Dying Patient (LCP).

Aim

The original aim was to assess the impact of the LCP on care in two settings: nursing homes and intensive care units (ICUs).

Design

Qualitative, matched case study.

Methods

Data were collected from 12 ICUs and 11 nursing homes in England: (1) documentary analysis of provider end-of-life care policy documents; (2) retrospective analysis of 10 deaths in each location using written case notes; (3) interviews with staff about end-of-life care; (4) observation of the care of dying patients; (5) analysis of the case notes pertaining to the observed patient’s death; (6) interview with a member of staff providing care during the observed period; (7) interview with a bereaved relative present during the observation; (8) economic analysis focused on the observed patients; and (9) strict inclusion and selection criteria for nursing homes and ICUs applied to match sites on LCP use/non-LCP use.

Results

It was not possible to meet the stated aims of the study. Although 23 sites were recruited, observations were conducted in only 12 sites (eight using the LCP). A robust comparison on the basis of LCP use could not, therefore, take place. Although nurses in both settings reported that the LCP supported good care, the LCP was interpreted and used differently across sites, with the greatest variation in ICUs. Although not able to address the original research question, this study provides an unprecedented insight into care at the end of life in two different settings. The majority of nursing homes had implemented some kind of ‘pathway’ for dying patients and most homes participating in the observational stage were using the LCP. However, training in care of the dying was variable and specific issues were identified relating to general practitioner involvement, the use of anticipatory drugs and the assessment of consciousness and the swallowing reflex. In ICUs, end-of-life care was inextricably linked with the withdrawal of active treatment and controlling the pace of death. The data highlight how the decision to withdraw was made and, importantly, how relatives were involved in this process. The fact that most patients died soon after the withdrawal of interventions was reported to limit the appropriateness of the LCP in this setting.

Limitations

Although the recruitment of matched sites was achieved, variable site participation resulted in a skewed sample. Issues with the sample size and a blurring of LCP use and non-use limit the extent to which the ambitious aims of the study were achieved.

Conclusions

This study makes a unique contribution to understanding the complexity of care at the end of life in two very different settings. More research is needed into the ways in which an organisational culture can be created within which the principles of good end-of-life care become translated into practice.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Balancing Legitimate Critical-Care Interests: Setting Defensible Care Limits Through Policy Development

Critical-care decision making is highly complex, given the need for health care providers and organizations to consider, and constructively respond to, the diverse interests and perspectives of a variety of legitimate stakeholders. Insights derived from an identified set of ethics-related considerations have the potential to meaningfully inform inclusive and deliberative policy development that aims to optimally balance the competing obligations that arise in this challenging, clinical decision-making domain. A potential, constructive outcome of such policy engagement is the collaborative development of an as-fair-as-possible dispute resolution process that incorporates an appropriated-justified, defensible critical-care obligation threshold.

Medical futility and end-of-life care: perspectives from practice. Coping with medical futility

Advances in technology a nd medical knowledge have dramatically altered our ability to sustain life in the Intensive Care Unit (ICU). Many things come into play for the nurse when establishing patient goals, respecting patient's wishes, and valuing spiritual and cultural beliefs in end-of-life care. A veteran ICU nurse shares the challenges of caring and how, she copes when medical interventions seem futile.

Supporting families of dying patients in the intensive care units

Family support in the intensive care units is a challenge for nurses who take care of dying patients. This article aimed to determine the Iranian nurses' experience of supporting families in end-of-life care. Using grounded theory methodology, 23 critical care nurses were interviewed. The theme of family support was extracted and divided into 5 categories: death with dignity; facilitate visitation; value orientation; preparing; and distress. With implementation of family support approaches, family-centered care plans will be realized in the standard framework.

End of life/palliative care/ethics

Palliative and end-of-life care, once the purview of oncologists and intensivists, has also become the responsibility of the emergency physician. As our population ages and medical technology enables increased longevity, it is essential that all medical professionals know how to help patients negotiate the balance between quantity and quality of life. Emergency physicians have the opportunity to educate patients and their loved ones on how to best accomplish their goals of care while also enhancing quality of life through treatment of symptoms. The emergency physician must be aware of the ethical and medico-legal parameters that govern decision making.

Decisions to withhold or withdraw life-sustaining treatment in a Norwegian intensive care unit

BACKGROUND

To withhold and withdraw treatment are important and difficult decisions made in the intensive care unit (ICU). The aim of this study was to investigate the incidence of withholding or withdrawing treatment, characteristics of the patients, and how these decision processes were handled and documented in a general ICU from 2007 to 2009 in a university hospital in Norway.

METHODS

Patient characteristics and outcomes of treatment were prospectively registered. We retrospectively reviewed the medical records for information on limitations in treatment.

RESULTS

In total, 1287 patients were admitted to the ICU. The ICU mortality was 208 (16%), and the hospital mortality was 341 (26%). In total, 301 patients (23%) had treatment withheld or withdrawn. Medical and unscheduled surgical patients with limitations in treatment had higher Simplified Acute Physiology Score II (P < 0.001) and were older (P < 0.001) than those without limitations in treatment. The most common main reason for withdrawing treatment was poor prognosis. According to the medical records, the patient was involved in the decision-making regarding withdrawal of treatment in only 2% of the cases, and the patient's relatives were involved in the decision-making in 77% of the cases. In 12% of the cases, type of treatment withdrawn was not documented.

CONCLUSION

Withholding or withdrawing treatment in the ICU was common. Medical and unscheduled surgical patients with limitations in treatment were older and more severely ill than patients without limitations. There is a potential for better documentation of the processes regarding withholding or withdrawing life-sustaining intensive care treatment.

Comparison of APACHE III, APACHE IV, SAPS 3, and MPM0III and influence of resuscitation status on model performance

BACKGROUND

There are few comparisons among the most recent versions of the major adult ICU prognostic systems (APACHE [Acute Physiology and Chronic Health Evaluation] IV, Simplified Acute Physiology Score [SAPS] 3, Mortality Probability Model [MPM]0III). Only MPM0III includes resuscitation status as a predictor.

METHODS

We assessed the discrimination, calibration, and overall performance of the models in 2,596 patients in three ICUs at our tertiary referral center in 2006. For APACHE and SAPS, the analyses were repeated with and without inclusion of resuscitation status as a predictor variable.

RESULTS

Of the 2,596 patients studied, 283 (10.9%) died before hospital discharge. The areas under the curve (95% CI) of the models for prediction of hospital mortality were 0.868 (0.854-0.880), 0.861 (0.847-0.874), 0.801 (0.785-0.816), and 0.721 (0.704-0.738) for APACHE III, APACHE IV, SAPS 3, and MPM0III, respectively. The Hosmer-Lemeshow statistics for the models were 33.7, 31.0, 36.6, and 21.8 for APACHE III, APACHE IV, SAPS 3, and MPM0III, respectively. Each of the Hosmer-Lemeshow statistics generated P values < .05, indicating poor calibration. Brier scores for the models were 0.0771, 0.0749, 0.0890, and 0.0932, respectively. There were no significant differences between the discriminative ability or the calibration of APACHE or SAPS with and without “do not resuscitate” status.

CONCLUSIONS

APACHE III and IV had similar discriminatory capability and both were better than SAPS 3, which was better than MPM0III. The calibrations of the models studied were poor. Overall, models with more predictor variables performed better than those with fewer. The addition of resuscitation status did not improve APACHE III or IV or SAPS 3 prediction.

Challenges in end-of-life decisions in the intensive care unit: an ethical perspective

When making end-of-life decisions in intensive care units (ICUs), different staff groups have different roles in the decision-making process and may not always assess the situation in the same way. The aim of this study was to examine the challenges Danish nurses, intensivists, and primary physicians experience with end-of-life decisions in ICUs and how these challenges affect the decision-making process. Interviews with nurses, intensivists, and primary physicians were conducted, and data is discussed from an ethical perspective. All three groups found that the main challenges were associated with interdisciplinary collaboration and future perspectives for the patient. Most of these challenges were connected with ethical issues. The challenges included different assessments of treatment potential, changes and postponements of withholding and withdrawing therapy orders, how and when to identify patients' wishes, and suffering caused by the treatment. To improve end-of-life decision-making in the ICU, these challenges need to be addressed by interdisciplinary teams.

Communication and advanced care planning in palliative and end-of-life care

Communication about and planning for the end of life has evolved with medical and technological changes. This article presents a focused literature review of Advance Directives (ADs), Advanced Care Planning (ACP), and communication in palliative and end-of-life care. Two focused Medline searches were conducted to locate articles that addressed ACP in the U.S. Content analysis was utilized to summarize and categorize the literature into five domains: (1) ADs, (2) ACP and communication, (3) Barriers to ACP, (4) Differential domains of ACP, and (5) Interventions to enhance the process. Policies and protocols for ACP and communication have been developed to facilitate the process in different patient populations and locations of care. Effective ACP is an essential component of person-centered end-of-life and palliative care.

Issues surrounding end-of-life decision-making

End-of-life decision-making is a complex process that can be extremely challenging. We describe a 42-year-old woman in an irreversible coma without an advance directive. The case serves to illustrate the complications that can occur in end-of-life decision-making and challenges in resolving difficult futility disputes. We review the role of advance directives in planning end-of-life care, the responsibility and historical performance of patient surrogates, the genesis of futility disputes, and approaches to resolving disputes.

Advance directives in the trauma intensive care unit: Do they really matter?

Despite advances in the care of the injured patient, 22% of trauma patients admitted to the intensive care unit will die from their injuries. As a majority of these deaths will occur due to withdrawal of care, intensivists should be proficient in their ability to discuss end-of-life care with patients and families. While the use of advance directives to document patients' wishes has increased, their utility is uncertain. We review the effectiveness and obstacles of advance directives.

Ethical aspects of using GPS for tracking people with dementia: recommendations for practice

BACKGROUND

Problems with out-of-home mobility are among the more common behavioral disturbances in dementia. Today people with dementia can be aided by easily accessible assistive technologies, such as tracking devices using Global Positioning Systems (GPS). Attitudes toward these technologies are still inconclusive and their use with people with dementia raises ethical concerns. The lack of ethical consensus on the use of GPS for people with dementia underlines the need for clearer policies and practical guidelines.

METHODS

Here we summarize qualitative and quantitative findings from a larger research project on the ethical aspects of using GPS for tracking people with dementia.

RESULTS

The findings are formulated in a list of recommendations for policy-makers as well as for professional and family caregivers. Among other points, the recommendations indicate that the preferences and best interests of the people with dementia should be central to the difficult decisions required in dementia care. Further, no-one should be coerced into using tracking technology and, where possible, people with dementia must be involved in the decision-making and their consent sought.

CONCLUSIONS

The decision whether, when and how to use GPS for tracking people with dementia should be made at the time of diagnosis jointly by the person with dementia, his/her family and professional caregivers. This decision should be made in formal structured meetings facilitated by a professional team.

The effect of statutory limitations on the authority of substitute decision makers on the care of patients in the intensive care unit: case examples and review of state laws affecting withdrawing or withholding life-sustaining treatment

While the ethics and critical care literature is replete with discussion of medical futility and the ethics of end-of-life care decisions in the intensive care unit, little attention is paid to the effect of statutory limitations on the authority of substitute decision makers during the course of treatment of patients in the critical care setting. In many jurisdictions, a clear distinction is made between the authority of a health care power of attorney, who is legally designated by a competent adult to make decisions regarding withholding or withdrawing life-sustaining treatment, and of next-of-kin, who are limited in this regard. However, next-of-kin are often relied upon to consent to necessary procedures to advance a patient's medical care. When conflicts arise between critical care physicians and family members regarding projected patient outcome and functional status, these statutory limitations on decision-making authority by next of kin can cause paralysis in the medical care of severely ill patients, leading to practical and ethical impasses. In this article, we will provide case examples of how statutory limitations on substitute decision making authority for next of kin can impede the care of patients. We will also review the varying jurisdictional limitations on the authority of substitute decision makers and explore their implications for patient care in the critical care setting. Finally, we will review possible ethical and legal solutions to resolve these impasses.

Association between education in EOL care and variability in EOL practice: a survey of ICU physicians

PURPOSE

This study investigated the association between physician education in EOL and variability in EOL practice, as well as the differences between beliefs and practices regarding EOL in the ICU.

METHODS

Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, as well physicians' personal, professional and EOL educational characteristics.

RESULTS

The response rate was 89%, with 105 questionnaires analyzed. Mean age was 38 ± 8 years, with a mean of 14 ± 7 years since graduation. Physicians who did not apply do-not-resuscitate (DNR) orders were less likely to have attended EOL classes than those who applied written DNR orders [0/7 vs. 31/47, OR = 0.549 (0.356-0.848), P = 0.001]. Physicians who involved nurses in the decision-making process were more likely to be ICU specialists [17/22 vs. 46/83, OR = 4.1959 (1.271-13.845), P = 0.013] than physicians who made such decisions among themselves or referred to ethical or judicial committees. Physicians who would apply "full code" had less often read about EOL [3/22 vs. 11/20, OR = 0.0939 (0.012-0.710), P = 0.012] and had less interest in discussing EOL [17/22 vs. 20/20, OR = 0.210 (0.122-0.361), P < 0.001], than physicians who would withdraw life-sustaining therapies. Forty-four percent of respondents would not do what they believed was best for their patient, with 98% of them believing a less aggressive attitude preferable. Legal concerns were the leading cause for this dichotomy.

CONCLUSIONS

Physician education about EOL is associated with variability in EOL decisions in the ICU. Moreover, actual practice may differ from what physicians believe is best for the patient.

Health care quality in end-of-life care: promoting palliative care in the intensive care unit

Seminal articles published in the late 1990s instigated not only an intense interest in health care quality but also a new era of research into quality end-of-life care, particularly in intensive care units (ICUs). ICUs can improve health care quality at the end of life by better using palliative care services and palliative care-related principles. This article details how the interest in health care quality has spurred a similar interest in end-of-life and palliative care in ICUs, defines palliative care and describes how it improves health care quality, and highlights barriers to the incorporation of palliative care in ICUs.

Withholding or withdrawing therapy in Danish regional ICUs: frequency, patient characteristics and decision process

BACKGROUND

New options for intensive therapy have increased the necessity of considering withholding or withdrawing therapy at intensive care units (ICUs), but the practice varies according to regional and cultural differences. The aim of this study was to investigate the frequency of withholding or withdrawing therapy in two secondary Danish ICUs, to describe the characteristics of patients in whom such decisions were made and to examine the existing documentation of the decision process.

METHODS

A retrospective review of hospital records for all patients admitted to two regional Danish ICUs in 2008. The records were searched for all information regarding deliberations or decisions on withholding or withdrawing therapy.

RESULTS

Of 1665 patients admitted to the ICUs, 176 patients (10.6%) died; of these, 34 (19.3%) died while still receiving full active therapy, 25 (14.2%) died after therapy was withheld and 117 (66.5%) died after therapy was withdrawn. An additional 88 patients (5.3%) were discharged alive with therapy either withheld or withdrawn. The patients who died had higher severity scores, were older and were more likely to be men than those who were discharged with full therapy. The main reasons for withholding or withdrawing therapy were prognosis for acute illness and the deemed futility of therapy. The median time from admission to a decision on withholding or withdrawing therapy was 1.4 days.

CONCLUSION

Withholding or withdrawing therapy is common in Danish ICUs but more research is needed to explore the different aspects of withholding or withdrawing therapy in Danish ICUs.

End of life decisions and care of the adult burn patient

INTRODUCTION

Despite advancements in the provision of burn care, there is still a significant cohort of patients who fail to respond to therapy or for whom treatment is deemed futile. The decision to withdraw support from, or to implement a Do-Not-Resuscitate (DNAR) order in, such patients can be challenging. Our aims were to review the withdrawal of life-sustaining treatment, issuing of DNAR orders and end of life care in burn patient deaths.

METHODS

A retrospective case notes review was undertaken, for all burn in-patient deaths from 1st April 2001 to 31st December 2007.

RESULTS

Following exclusions, 63 patients were included in our study, with a median age of 56 years (21-94). End of life decisions in younger patients (under 65 years) were more often due to burn severity. In those over 65 years, reasons were due to co-morbidities, and these decisions were made late in the patient's admission. In 34% of patients, end of life care was not comprehensively documented.

CONCLUSION

A coherent, decisive approach should be adopted and adhered to by all members of the multi-disciplinary team, with clear, standardised documentation in place.

Physician communication with families in the ICU: evidence-based strategies for improvement

PURPOSE OF REVIEW

Skilled physician-family communication in the ICU has been shown to improve patient outcomes, but until now little attention has been given to the effect of communication on family satisfaction and bereavement outcomes. The aim of this review is to outline the recent evidence that effective physician communication with families, and proactive palliative care interventions, can improve outcomes for both patients and family members in the ICU.

RECENT FINDINGS

New data from the ICU correlates physician ability to identify and respond to emotion and to effectively share prognostic information with improved outcomes. Furthermore, proactive palliative care interventions that promote family meetings, use of empathic communication skills, and targeted palliative care consultations can improve family satisfaction, reduce length of stay in the ICU and reduce adverse family bereavement outcomes.

SUMMARY

Empathic communication, skilful discussion of prognosis, and effective shared decision-making are core elements of quality care in the ICU, represent basic competencies for the ICU physician, and should be emphasized in future educational and clinical interventions.