The Influence of Geography, Religion, Religiosity and Institutional Factors on Worldwide End-of-Life Care for the Critically Ill: The WELPICUS Study

OBJECTIVE

To evaluate the association between provider religion and religiosity and consensus about end-of-life care and explore if geographical and institutional factors contribute to variability in practice.

METHODS

Using a modified Delphi method 22 end-of-life issues consisting of 35 definitions and 46 statements were evaluated in 32 countries in North America, South America, Eastern Europe, Western Europe, Asia, Australia and South Africa. A multidisciplinary, expert group from specialties treating patients at the end-of-life within each participating institution assessed the association between 7 key statements and geography, religion, religiosity and institutional factors likely influencing the development of consensus.

RESULTS

Of 3049 participants, 1366 (45%) responded. Mean age of respondents was 45 ± 9 years and 55% were females. Following 2 Delphi rounds, consensus was obtained for 77 (95%) of 81 definitions and statements. There was a significant difference in responses across geographical regions. South African and North American respondents were more likely to encourage patients to write advance directives. Fewer Eastern European and Asian respondents agreed with withdrawing life-sustaining treatments without consent of patients or surrogates. While respondent's religion, years in practice or institution did not affect their agreement, religiosity, physician specialty and responsibility for end-of-life decisions did.

CONCLUSIONS

Variability in agreement with key consensus statements about end-of-life care is related primarily to differences among providers, with provider-level variations related to differences in religiosity and specialty. Geography also plays a role in influencing some end-of-life practices. This information may help understanding ethical dilemmas and developing culturally sensitive end-of-life care strategies.

Physicians' experiences and perceptions about withholding and withdrawal life-sustaining treatment in Chiang Mai University Hospital: a cross-sectional study

BACKGROUND

Withholding or withdrawing life-sustaining treatment in end-of-life patients is a challenging ethical issue faced by physicians. Understanding physicians' experiences and factors influencing their decisions can lead to improvement in end-of-life care.

OBJECTIVES

To investigate the experiences of Thai physicians when making decisions regarding the withholding or withdrawal of life-sustaining treatments in end-of-life situations. Additionally, the study aims to assess the consensus among physicians regarding the factors that influence these decisions and to explore the influence of families or surrogates on the decision-making process of physicians, utilizing case-based surveys.

METHODS

A web-based survey was conducted among physicians practicing in Chiang Mai University Hospital (June - October 2022).

RESULTS

Among 251 physicians (response rate 38.3%), most of the respondents (60.6%) reported that they experienced withholding or withdrawal treatment in end-of-life patients. Factors that influence their decision-making include patient's preferences (100%), prognosis (93.4%), patients' quality of life (92.8%), treatment burden (89.5%), and families' request (87.5%). For a chronic disease with comatose condition, the majority of the physicians (47%) chose to continue treatments, including cardiopulmonary resuscitation (CPR). In contrast, only 2 physicians (0.8%) would do everything, in cases when families or surrogates insisted on stopping the treatment. This increased to 78.1% if the families insisted on continuing treatment.

CONCLUSION

Withholding and withdrawal of life-sustaining treatments are common in Thailand. The key factors influencing their decision-making process included patient's preferences and medical conditions and families' requests. Effective communication and early engagement in advanced care planning between physicians, patients, and families empower them to align treatment choices with personal values.

Muslims and End-of-Life Healthcare in Non-Muslim Majority Nations: A Systematic Literature Review

CONTEXT

As Muslim populations in non-Muslim majority nations grow and age, they will increasingly require culturally appropriate healthcare. Delivering such care requires understanding their experiences with, as well as preferences regarding, end-of-life healthcare.

OBJECTIVES

To examine the experiences, needs, and challenges of Muslim patients and caregivers with end-of-life, hospice, and palliative care.

METHODS

A systematic literature review using five databases (MEDLINE, Scopus, Web of Science, CINAHL, Cochrane Library) and key terms related to Islam and end-of-life healthcare. Papers were limited to English-language empirical studies of adults in non-Muslim majority nations. After removing duplicates, titles, abstracts, and articles were screened for quality and reviewed by a multidisciplinary team.

RESULTS

From an initial list of 1867 articles, 29 articles met all inclusion criteria. Most studies focused on end-of-life healthcare not related to palliative or hospice services and examined Muslim patient and caregiver experiences rather than their needs or challenges. Content analysis revealed three themes: (1) the role of family in caregiving as a moral duty and as surrogate communicators; (2) gaps in knowledge among providers related to Muslim needs and gaps in patient/family knowledge about advance care planning; and (3) the influence of Islam on Muslim physicians' perspectives and practices.

CONCLUSION

There is scant research on Muslim patients' and caregivers' engagement with end-of-life healthcare in non-Muslim majority nations. Existing research documents knowledge gaps impeding both Muslim patient engagement with end-of-life care and the delivery of culturally appropriate healthcare.

The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review

Decisions in end-of-life care are influenced by several factors, many of which are not identified by the decision maker. These influencing factors modify important decisions in this scenario, such as in decisions to adapt to therapeutic support. This presented scoping review aims to map the factors that influence end-of-life care decisions for adult and older adult patients, by a scoping review. The review was carried out in 19 databases, with the keyword 'clinical decision-making' AND 'terminal care' OR 'end-of-life care' and its analogues, including publications from 2017 to 2022. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The search resulted in 3474 publications, where the presence of influencing factors in end-of-life decision-making for adults and the elderly was applied as a selection criterion. Fifty-four (54) of them were selected, which means 1.5% of all the results. Among the selected publications, 89 influencing factors were found, distributed in 54 (60.6%) factors related to the health team, 18 (20.2%) to patients, 10 (11.2%) related to family or surrogates and 7 (7.8%) factors related to the decision environment. In conclusion, we note that the decision-making in end-of-life care is complex, mainly because there is an interaction of different characters (health team, patient, family, or surrogates) with a plurality of influencing factors, associated with an environment of uncertainty and that result in a critical outcome, with a great repercussion for the end of life, making it imperative the recognition of these factors for more competent and safe decision-making.

Career Satisfaction and Burnout among American Muslim Physicians

Background  Career satisfaction and burnout among physicians are important to study because they impact healthcare quality, outcomes, and physicians' well-being. Relationships between religiosity and these constructs are underexplored, and Muslim American physicians are an understudied population. Methods  To explore relationships between career satisfaction, burnout, and callousness and Muslim physician characteristics, a questionnaire including measures of religiosity, career satisfaction, burnout, callousness, and sociodemographic characteristics was mailed to a random sample of Islamic Medical Association of North America members. Statistical relationships were explored using chi-squared tests and logistic regression models. Results  There were 255 respondents (41% response rate) with a mean age of 52 years. Most (70%) were male, South Asian (70%), and immigrated to the United States as adults (65%). Nearly all (89%) considered Islam the most or very important part of their life, and 85% reported being somewhat or very satisfied with their career. Multivariate models revealed that workplace accommodation of religious identity is the strongest predictor of career satisfaction (odds ratio [OR]: 2.69, p  = 0.015) and that respondents who considered religious practice to be the most important part of their lives had higher odds of being satisfied with their career (OR: 2.21, p  = 0.049) and lower odds of burnout (OR: 0.51, p  = 0.016). Participants who felt that their religion negatively influenced their relationships with colleagues had higher odds of callousness (OR: 2.25, p  = 0.003). Conclusions  For Muslim physicians, holding their religion to be the most important part of their life positively associates with career satisfaction and lower odds of burnout and callousness. Critically, perceptions that one's workplace accommodates a physician's religious identity associate strongly with career satisfaction. In this era of attention to physician well-being, the importance of religiosity and religious identity accommodations to positive career outcomes deserves focused policy attention.

Comparison of Clinical Characteristics and End-of-Life Care Between COVID-19 and Non-COVID-19 Muslim Patients During the 2020 Pandemic

Background:

Little is known about end-of-life care among Muslim patients, particularly during Coronavirus disease 2019 (COVID) pandemic, which we report here.

Methods:

The clinical characteristics, end-of-life care and resuscitation status of Muslim patients who died in the ICU of our tertiary care hospital in year 2020 from COVID were compared to Non-COVID patients.

Results:

There were 32 patients in COVID and 64 in the Non-COVID group. A major proportion, mainly of Non-COVID patients, already had a hospice eligible terminal disease at baseline (p=.002). COVID patients were admitted to the ICU sooner after hospitalization (2.2 vs. 17 days), had prolonged duration of mechanical ventilation (18.5 vs. 6 days) and longer ICU stay (24 vs. 8 days) than non-COVID patients, respectively (p<.001). Almost all patients were “Full Code” initially. However, status was eventually changed to ‘do-not-attempt resuscitation’ (DNAR) in about 60% of the cohort. COVID patients were made DNAR late in their ICU stay, predominantly in the last 24 hours of life (p=.04). Until the very end, patients in both groups were on tube feeds, underwent blood draws and imaging, required high dose vasopressors, with few limitations or withdrawal of therapies. Family members were usually not present at bedside at time of death. There was minimal involvement of chaplain and palliative care services.

Conclusions:

Muslim COVID-19 patients had prolonged mechanical ventilation and ICU stay and a delayed decision to DNAR status than non-COVID Muslim patients. Limitation or withdrawal of therapy occurred infrequently. The utilization of chaplain and palliative care service needs improvement.

Factors affecting the attitudes and opinions of ICU physicians regarding end-of-life decisions for their patients and themselves: A survey study from Turkey

Introduction

Turkey is constitutionally secular with a Muslim majority. There is no legal basis for limiting life-support at the end-of-life (EOL) in Turkey. We aimed to investigate the opinions and attitudes of intensive care unit (ICU) physicians regarding EOL decisions, for both their patients and themselves, and to evaluate if the physicians’ demographic and professional variables predicted the attitudes of physicians toward EOL decisions.

Methods

An online survey was distributed to national critical care societies’ members. Physicians’ opinions were sought concerning legalization of EOL decisions for terminally ill patients or by patient-request regardless of prognosis. Participants physicians’ views on who should make EOL decisions and when they should occur were determined. Participants were also asked if they would prefer cardiopulmonary resuscitation (CPR) and/or intubation/mechanical ventilation (MV) personally if they had terminal cancer.

Results

A total of 613 physicians responded. Religious beliefs had no effect on the physicians’ acceptance of do-not-resuscitate (DNR) / do-not-intubate (DNI) orders for terminally ill patients, but atheism, was found to be an independent predictor of approval of DNR/DNI in cases of patient request (p<0.05). While medical experience (≥6 years in the ICU) was the independent predictor for the physicians’ approval of DNI decisions on patient demand, the volume of terminal patients in ICUs (between 10–50% per year) where they worked was an independent predictor of physicians’ approval of DNI for terminal patients. When asked to choose personal options in an EOL scenario (including full code, only DNR, only DNI, both DNR and DNI, and undecided), younger physicians (30–39 years) were more likely to prefer the "only DNR" option compared with physicians aged 40–49 years (p<0.05) for themselves and age 30–39 was an independent predictor of individual preference for "only DNR” at the hypothetical EOL. Physicians from an ICU with <10% terminally ill patients were less likely to prefer "DNR" or "DNR and DNI" options for themselves at EOL compared with physicians who worked in ICUs with a higher (>50%) terminally ill patient ratio (p<0.05).

Conclusion

Most ICU physicians did not want legalization of DNR and DNI orders, based solely on patient request. Even if EOL decision-making were legal in Turkey, this attitude may conflict with patient autonomy. The proportion of terminally ill patients in the ICU appears to affect physicians’ attitudes to EOL decisions, both for their patients and by personal preference, an association which has not been previously reported.