Cultural differences at the end of life

The Gap in Attitudes Toward Withholding and Withdrawing Life-Sustaining Treatment Between Japanese Physicians and Citizens

BACKGROUND

According to some medical ethicists and professional guidelines, there is no ethical difference between withholding and withdrawing life-sustaining treatment. However, medical professionals do not always agree with this notion. Patients and their families may also not regard these decisions as equivalent. Perspectives on life-sustaining treatment potentially differ between cultures and countries. This study compares Japanese physicians' and citizens' attitudes toward hypothetical cases of withholding and withdrawing life-sustaining treatment.

METHODS

Ten vignette cases were developed. A web-based questionnaire was administered to 457 citizens and 284 physicians to determine whether they supported withholding or withdrawing treatment.

RESULTS

In a case where a patient had an advance directive refusing ventilation, 77% of the physicians and 68% of the citizens chose to withhold treatment. In a case where there was an advance directive but the patient's family requested treatment, 55% of the physicians and 45% of the citizens chose to withhold the ventilator. When a family requested withdrawal of the ventilator but patient wishes were unknown, 19% of the physicians and 48% of the citizens chose to withdraw the ventilator. However, when the patient had also indicated their wishes in writing, 49% of the physicians and 66% of the citizens chose to withdraw treatment. More physicians were prepared to withdraw dialysis (84%) and artificial nutrition (81%) at a patient's request than mechanical ventilation (49%).

CONCLUSIONS

A significant proportion of Japanese physicians and citizens were reluctant to withhold or withdraw life-sustaining treatment, even in cases where the patient had indicated their wishes in writing. They were more likely to withhold than withdraw treatment, and more likely to withdraw artificial nutrition than mechanical ventilation. Japanese physicians gave significant weight to family views about treatment but were less likely to agree to withdraw treatment than citizens, indicating a potential source of conflict in clinical settings.

Greek Orthodox

There are approximately 300 million members of the Greek Orthodox Church worldwide. It is the second-largest Christian church. Followers of this religion believe in eternal life. Thus, the church strongly emphasizes a positive outcome in death- "the deceased is alive with God." God is believed to be the healer of our souls and bodies, which is facilitated through prayer and participation in the life of the Church. Traditional medical interventions are generally accepted. Artificial life support is justifiable only when it offers a hope for meaningful recovery. Just as death should not be hastened, the natural dying process should not be prolonged. Timely advance care planning and early treatment goals discussions to help understand how the patient would define quality of life is paramount to setting limitations on what could be considered as nonbeneficial care. The medical team should not assume that all patients of the Greek Orthodox faith will feel the same around end-of-life beliefs and practices. This chapter aims to identify common themes and the historical contextual framework that may influence the way in which medical decision making is made by those who specifically subscribe to the Greek Orthodox faith.

Consequences of suboptimal communication for patients with limited English proficiency in the intensive care unit and suggestions for a way forward: A qualitative study of healthcare team perceptions

PURPOSE

To understand the healthcare team's perceptions of the negative consequences of suboptimal communication and their recommendations to improve communication with patients and families who have Limited English Proficiency (LEP) in the Intensive Care Unit (ICU).

MATERIALS AND METHODS

We performed a qualitative study using semi-structured interviews of physicians, nurses, and interpreters from 3 ICUs at Mayo Clinic Rochester, between November 2017 and April 2018.

RESULTS

We identified 5 consequences of suboptimal communication: 1) Suboptimal assessment and treatment of patient symptoms, 2) Unmet patient and family expectations, 3) Decreased patient autonomy, 4) Unmet end of life wishes and 5) Clinician Distress. Recommendations to improve communication include: 1) Education and training for patients,families, clinicians and interpreters, 4) Greater integration of interpreters into the ICU team 5) Standardized timeline for goals of care conversations with patients and families with LEP.

CONCLUSIONS

Patients with LEP are at risk of experiencing suboptimal communication with the healthcare team in the ICU. There are several educational and quality improvement strategies that ICUs and institutions can take to mitigate these issues.

Artificial Intelligence in the Intensive Care Unit

The diffusion of electronic health records collecting large amount of clinical, monitoring, and laboratory data produced by intensive care units (ICUs) is the natural terrain for the application of artificial intelligence (AI). AI has a broad definition, encompassing computer vision, natural language processing, and machine learning, with the latter being more commonly employed in the ICUs. Machine learning may be divided in supervised learning models (i.e., support vector machine [SVM] and random forest), unsupervised models (i.e., neural networks [NN]), and reinforcement learning. Supervised models require labeled data that is data mapped by human judgment against predefined categories. Unsupervised models, on the contrary, can be used to obtain reliable predictions even without labeled data. Machine learning models have been used in ICU to predict pathologies such as acute kidney injury, detect symptoms, including delirium, and propose therapeutic actions (vasopressors and fluids in sepsis). In the future, AI will be increasingly used in ICU, due to the increasing quality and quantity of available data. Accordingly, the ICU team will benefit from models with high accuracy that will be used for both research purposes and clinical practice. These models will be also the foundation of future decision support system (DSS), which will help the ICU team to visualize and analyze huge amounts of information. We plea for the creation of a standardization of a core group of data between different electronic health record systems, using a common dictionary for data labeling, which could greatly simplify sharing and merging of data from different centers.

Bridging the Continuum: Nutrition Support in Palliative and Hospice Care

Clinicians and patients in today's technically focused healthcare environment are often faced with decisions of what should be done vs what could be done. The decision to provide or not provide nutrition support during palliative care and hospice care requires an understanding of and respect for patient wishes, an appreciation for the expectations of the patient and family, and open and effective communication. There can be confusion and disagreement concerning what nutrition therapies should be continued and which ones stopped. These decisions can be facilitated by answering the question: When do the burdens of nutrition support outweigh the benefit to the patient? The patient, family members, and healthcare providers should openly discuss and agree upon the goals of nutrition support during palliative care and hospice care.

End-of-Life Practices in the Intensive Care Unit: The Importance of Geography, Religion, Religious Affiliation, and Culture

End-of-life decisions are made daily in intensive care units worldwide. There are numerous factors affecting these decisions, including geographical location as well as religion and attitudes of caregivers, patients, and families. There is a spectrum of end-of-life care options from full continued care, withholding treatment, withdrawing treatment, and active life-ending procedures.

Perspectives of physicians and nurses regarding end-of-life care in the intensive care unit

CONTEXT

The delivery of end-of-life care (EOLC) in the intensive care unit (ICU) varies widely among medical care providers. The differing opinions of nurses and physicians regarding EOLC may help identify areas of improvement.

OBJECTIVE

To explore the differences of physicians and nurses on EOLC in the ICU and how these differences vary according to self-reported proficiency level and primary work unit.

DESIGN

Cross-sectional survey of 69 ICU physicians and 629 ICU nurses.

SETTING

Single tertiary care academic medical institution.

RESULTS

A total of 50 physicians (72%) and 331 nurses (53%) participated in the survey. Significant differences between physicians and nurses were noted in the following areas: ability to safely raise concerns, do not resuscitate (DNR) decision making, discussion of health care directives, timely hospice referral, spiritual assessment documentation, utilization of social services, and the availability of EOLC education. In every domain of EOLC, physicians reported a more positive perception than nurses. Additional differences were noted among physicians based on experience, as well as among nurses based on their primary work unit and self-reported proficiency level.

CONCLUSIONS

Even with an increased focus on improving EOLC, significant differences continue to exist between the perspectives of nurses and physicians, as well as physicians among themselves and nurses among themselves. These differences may represent significant barriers toward providing comprehensive, consistent, and coordinated EOLC in the ICU.

End-of-life decisions in Greek intensive care units: a multicenter cohort study

Introduction

Intensive care may prolong the dying process in patients who have been unresponsive to the treatment already provided. Limitation of life-sustaining therapy, by either withholding or withdrawing support, is an ethically acceptable and common worldwide practice. The purpose of the present study was to examine the frequency, types, and rationale of limiting life support in Greek intensive care units (ICUs), the clinical and demographic parameters associated with it, and the participation of relatives in decision making.

Methods

This was a prospective observational study conducted in eight Greek multidisciplinary ICUs. We studied all consecutive ICU patients who died, excluding those who stayed in the ICU less than 48 hours or were brain dead.

Results

Three hundred six patients composed the study population, with a mean age of 64 years and a mean APACHE II score on admission of 21. Of study patients, 41% received full support, including unsuccessful cardiopulmonary resuscitation (CPR); 48% died after withholding of CPR; 8%, after withholding of other treatment modalities besides CPR; and 3%, after withdrawal of treatment. Patients in whom therapy was limited had a longer ICU (P < 0.01) and hospital (P = 0.01) length of stay, a lower Glasgow Coma Scale score (GCS) on admission (P < 0.01), a higher APACHE II score 24 hours before death (P < 0.01), and were more likely to be admitted with a neurologic diagnosis (P < 0.01). Patients who received full support were more likely to be admitted with either a cardiovascular (P = 0.02) or trauma diagnosis (P = 0.05) and to be surgical rather than medical (P = 0.05). The main factors that influenced the physician's decision were, when providing full support, reversibility of illness and prognostic uncertainty, whereas, when limiting therapy, unresponsiveness to treatment already offered, prognosis of underlying chronic disease, and prognosis of acute disorder. Relatives' participation in decision making occurred in 20% of cases and was more frequent when a decision to provide full support was made (P < 0.01). Advance directives were rare (1%).

Conclusions

Limitation of life-sustaining treatment is a common phenomenon in the Greek ICUs studied. However, in a large majority of cases, it is equivalent to the withholding of CPR alone. Withholding of other therapies besides CPR and withdrawal of support are infrequent. Medical paternalism predominates in decision making.

End-of-life treatment and bacterial antibiotic resistance: a potential association

BACKGROUND

Great variability exists in the occurrence of antibiotic-resistant bacteria in ICUs around the world. The contribution of specific ICU care variables to these geographic variations is unknown.

METHODS

ICU patients from two ICUs (in Jerusalem and Toronto) who were admitted for > 48 h and who grew a resistant bacteria in any culture during ICU admission were compared with those without resistant organisms across a range of demographic and ICU care interventions. Significant variables were investigated with logistic regression to identify factors predictive of infection/colonization with a resistant organism.

RESULTS

Resistant organisms were acquired by 82/423 (19%) patients. Patients acquiring a resistant organism had a higher incidence of diabetes mellitus (21/82, 26% vs 52/341, 15%; P = .026), were more frequently admitted from another ICU (17/82, 21% vs 33/341, 10%; P = .005), received more antibiotics in the ICU (19 +/- 17 vs 14 +/- 14 days; P = .005), and had more ventilator (10 +/- 10 vs 7 +/- 8; P = .031) and central line days (10 +/- 8 vs 7 +/- 8; P < .001). These patients had a lower incidence of limitation-of-therapy orders (9/82, 11% vs 78/341, 23%; P = .015). Only the absence of a limitation-of-therapy order (odds ratio, 2.62; 95% CI, 1.21-5.68; P = .014) was independently associated with the acquisition of resistant organisms. Further, among ICU fatalities, 5/45 (11%) patients acquired a resistant organism prior to withdrawal vs 17/44 (39%) nonwithdrawal fatalities (P = .003). Nonwithdrawal fatalities received significantly more third-line antibiotics (7 +/- 14 vs 2 +/- 4; P = .031) despite similar ICU lengths of stay (15 +/- 21 days for nonwithdrawal fatalities vs 10 +/- 11 for withdraw fatalities; P = .210)

CONCLUSIONS

End-of-life treatment is independently associated with acquisition of resistant bacteria. Patients dying without withdraw orders receive more antibiotics and develop more resistant organisms. These patients may represent a reservoir of resistant bacteria in the ICU.

Withdrawing Life-Sustaining Treatment: Ethical Considerations

Withdrawing life-supporting technology from patients who are irremediably ill is morally troubling for caregivers, patients, and families. Interventions that enable clinicians to delay death create situations in which the dignity and comfort of dying patients may be sacrificed to spare professionals and families from their elemental fear of death. Understanding of the limits of treatment, expertise in palliation of symptoms, skillful communication, and careful orchestration of controllable events can help to manage the withdrawal of life support appropriately.

Forgoing life sustaining treatments: differences and similarities between North America and Europe

BACKGROUND

As evidence exist that severe neurological damage or prolonged death after inappropriate CPR could occur, restraints and indications for CPR were perceived as necessary. The objective of this review is to examine policies and attitudes towards end-of-life decisions in Europe and North America and to outline differences and similarities.

METHODS

A bibliographic database search from 1990 to 2006 was performed using the following terms: do-not-resuscitate orders, end-of-life decisions, withholding/withdrawal of life-sustaining treatments, medical futility and advanced directives. Eighty-eight articles, out of 305 examined, were analyzed and their data systematically reported and compared where possible. They consisted of studies, questionnaires and surveys answering the following questions: percentage of deaths of critical patients preceded by do-not-resuscitate orders, factors affecting the decision for do-not-resuscitate orders, people involved in this decision (patient, surrogates and medical staff) and how it was performed.

RESULTS

There is an evident gap between the North American use of standard and formal procedures compared with Europe. Second, they diverge in the role acknowledged to surrogates in the decisional process, as in Europe, restraints and reserves to accept surrogates as decision makers seem still strong and a paternalistic approach at the end-of-life is still present.

CONCLUSION

Incidentally, despite the predictable differences between Europe and North America, concerns do exist about the actual extent of autonomy wished by patients and surrogates. It is important to highlight these findings, as the paternalistic attitude, too often negatively depicted, could be, according to the best medical practice, justified and more welcomed in some instances.

Care at the end of life in critically ill patients: the European perspective

PURPOSE OF REVIEW

Care surrounding end-of-life has become a major topic in the intensive care medicine literature. Cultural and regional variations are associated with transatlantic debates about decisions to forego life-sustaining therapies and lead to recent international statements. The aim of this review is to provide insight into the decisions to forego life sustaining therapies and end-of-life care in Europe.

RECENT FINDINGS

Although decisions to forego life-sustaining therapies are increasingly made in European countries, frequency and characteristics of end-of-life care are still heterogeneous. Moreover, even though many determinants of these variations have been identified, epidemiologic and interventional studies still provide additional information. In agreement with public opinions, recent European laws have emphasized the patient's autonomy. In real life, advance care planning is rarely used. Decisions are often made by caregivers (physicians and nurses) or families, these latter being less involved than in North America. Not only ethic divergences between physicians but also cultural variations account for this disparity.

SUMMARY

To optimize end-of-life care in the intensive care unit, there is an urgent need for the development of palliative and multidisciplinary care in Europe. Furthermore, it highlights the need for culturally competent care, adapted to needs and values of every single patient and family. In addition, a lack of communication with families and within the medical team, an uninformed public about end-of-life issues, and insufficient training of intensive care unit staff are crucial barriers to end-of-life care development. Special awareness of professionals and innovative research are needed to promote a high-standard of end-of-life care in the intensive care unit.

Withdrawing life-sustaining treatment: ethical considerations

In the community of caregivers, there is a general consensus that some heroic measures are not obligatory in certain circumstances that are defined by professional norms. For example, cardiopulmonary resuscitation in terminal cancer patients is not endorsed because of its violation of the dignity of the irremediably ill, and its unproductive cost to society. Moving back from this extreme, the availability and effectiveness of life-prolonging treatments, such as ventilators, dialysis, and implantable mechanical hearts, moves into a domain where the boundary limit of the obligation to preserve life is less clearly defined. When the continuing intervention of caregivers is essential to the prolongation of life, but the outcome and quality of residual life has deteriorated far below everyone's expectations when the treatment was initiated, caregivers are morally troubled as their treatments prolong the process of dying. Uncertainty or disputation about the prognosis raises the voltage of the fear and potential remorse that is a normal condition of care and support at the end of life. Unilateral decisions and overruling of objections should be avoided when possible, and reinforced by legal or ethical authorities when necessary. An ethics consultant, especially one skilled and experienced in management of end-of-life issues, can be a helpful negotiator and guide. The transition to palliative support should include the discontinuation of all unnecessary monitoring devices and tubes. Monitors should be turned off allowing families to direct their attention to the patient. Removing the monitor relieves family members from painful suspense and confusion. Removing the endotracheal tube sometimes allows conscious patients to talk to their loved ones, ending a silence forced on them by their treatment. If interventions are seen as masking the natural dying process, removing them should not be troubling. Their absence gives moral clarity to the elemental moments of closure at the end of life, no longer masked by futile contrivance. Withdrawal of life-sustaining treatment is a process that "merits the same meticulous preparation and expectation of quality that clinicians provide when they perform other procedures to initiate life support". Families and patients should never feel abandoned during this process and attention should be devoted to communicating that care is not being withdrawn. The family needs to be prepared for what the dying process may look like. Assure them that all energy is now being directed toward the comfort of the patient including sedation as required if signs of suffering are observed. Easing death, like easing birth, can be one of the most fulfilling contributions one can make to reduce the suffering and enrich the lives of patients and their families. Neglecting this part of the duty to provide appropriate care brings moral anguish to all participants in the peculiar circumstances that have come to surround death in the ICUs of developed countries. It is helpful to accept the inevitable reality that death is, in Shakespeare's words, a "necessary end" to all mortal life, and to recognize that defying death with technology can sometimes become an unnatural and degrading activity, however well motivated. The withdrawal of life-sustaining treatment, when conducted expertly, is a shared human experience that can be gratifying, although difficult for all concerned.

Ethical issues in intensive care--a survey among Scandinavian intensivists

BACKGROUND

The general principles of medical ethics are universally accepted. In practice, however, there is variation on how these principles are interpreted by people with different cultural backgrounds. The aim of this study was to document the views of Scandinavian intensive care physicians on intensive care unit (ICU) admission, triage, withholding and withdrawal of intensive care, and communication between the patient, the family and the ICU team.

METHODS

A questionnaire was developed and sent to 84 intensive care physicians working in Denmark, Finland, Sweden and Norway.

RESULTS

The response rate was 61%. In general, the responses were in agreement with published guidelines. Nevertheless, there was considerable variation on what factors are taken into account when priority decisions are made. In addition, the views on the content of information provided to the family varied. A majority of 80% reported priority decisions being made on a regular basis. Less than one-half of the respondents had correct knowledge regarding the existence or lack of national guidelines on intensive care ethics. Only 8% of the respondents were aware of guidelines published by the Society of Critical Care Medicine.

CONCLUSION

Variation in priority determinants between individual physicians may compromise justice in health care. An effort should be made to discuss and adopt mutual principles. In addition, the quality of information available to the patients' representatives deserves our attention. The results of this study could be used as a basis for discussion when guidelines on the ethical aspects of intensive care are developed and reviewed.

Limitation and withdrawal of intensive therapy at the end of life: practices in intensive care units in Mumbai, India

OBJECTIVE

To describe the practices in intensive care units in Mumbai hospitals regarding limitation and withdrawal of care at the end of life.

DESIGN

Review of prospectively collected data.

SETTINGS

Intensive care units of four major hospitals (two private tertiary referral general hospitals, one mixed public and private cancer referral hospital, and one large public hospital).

PATIENTS

Hospital and intensive care unit patients who died during the study period.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

We measured the percentage of hospital deaths occurring inside and outside intensive care units and the incidence of withholding intubation, withholding other therapy, and withdrawing therapy for deaths in the intensive care unit. The proportion of hospital deaths that occurred in an intensive care unit was 14% in the cancer hospital, 23% in the public hospital, and 58-73% in the two private hospitals (chi-square test for trends, p < .0001). Of the 143 deaths that occurred in intensive care unit, limitation of care occurred in 49 patients. Twenty-five percent of these patients were not intubated terminally, 67% were initially intubated and ventilated but failed to recover and subsequently had no further escalation of therapy, and 8% had withdrawal of therapy. Therapy was limited in 19% of deaths in the public hospital intensive care unit (odds ratio, 0.44; 95% confidence interval, 0.2-0.97) vs. 40%, 41%, and 50% of deaths in the other three intensive care units.

CONCLUSIONS

Therapy is limited in a significant proportion of intensive care unit patients. Significant differences in the practice of limitation of therapy exist between public and private hospitals. Lack of access to a limited number of intensive care unit beds, especially in the public hospital, may constitute implicit limitation of care.

Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil

OBJECTIVES

To study the possible change on mode of deaths, medical decision practices, and family participation on decisions for limiting life-sustaining treatments (L-LST) over a period of 13 yrs in three pediatric intensive care units (PICUs) located in southern Brazil.

METHODS

A cross-sectional study based on a retrospective chart review (1988 and 1998) and on prospective data collection (from May 1999 to May 2000).

SETTING

Three PICUs in Porto Alegre, southern Brazilian region.

PATIENTS

Children who died in those PICUs during the years of 1988, 1998, and between May 1999 and May 2000.

RESULTS

The 3 PICUs admitted 6,233 children during the study period with a mortality rate of 9.2% (575 deaths), and 509 (88.5%) medical charts were evaluated in this study. Full measures for life support (F-CPR) were recognized in 374 (73.5%) children before dying, brain death (BD) was diagnosed in 43 (8.4%), and 92 (18.1%) underwent some limitation of life support treatment (L-LST) There were 140 (27.5%) deaths within the first 24 hrs of admission and 128 of them (91.4%) received F-CPR, whereas just 11 (7.9%) patients underwent L-LST. The average length of stay for the death group submitted to F-CPR was lower (3 days) than the L-LST group (8.5 days; p < .05). The rate of F-CPR before death decreased significantly between 1988 (89.1%) and 1999/2000 (60.8%), whereas the L-LST rose in this period from 6.2% to 31.3%. These changes were not uniform among the three PICUs, with different rates of L-LST (p < .05). The families were involved in the decision-making process for L-LST in 35.9% of the cases, increasing from 12.5% in 1988 to 48.6% in 1999/2000. The L-LST plans were recorded in the medical charts in 76.1% of the deaths, increasing from 50.0% in 1988 to 95.9% in 1999/2000.

CONCLUSION

We observed that the modes of deaths in southern Brazilian PICUs changed over the last 13 yrs, with an increment in L-LST. However, this change was not uniform among the studied PICUs and did not reach the levels described in countries of the Northern Hemisphere. Family participation in the L-LST decision-making process has increased over time, but it is still far behind what is observed in other parts of the world.

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.