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

Limitation of life sustaining therapy in disorders of consciousness: ethics and practice

Clinical conversations surrounding the continuation or limitation of life-sustaining therapies (LLST) are both challenging and tragically necessary for patients with disorders of consciousness (DoC) following severe brain injury. Divergent cultural, philosophical and religious perspectives contribute to vast heterogeneity in clinical approaches to LLST-as reflected in regional differences and inter-clinician variability. Here we provide an ethical analysis of factors that inform LLST decisions among patients with DoC. We begin by introducing the clinical and ethical challenge and clarifying the distinction between withdrawing and withholding life-sustaining therapy. We then describe relevant factors that influence LLST decision-making including diagnostic and prognostic uncertainty, perception of pain, defining a 'good' outcome, and the role of clinicians. In concluding sections, we explore global variation in LLST practices as they pertain to patients with DoC and examine the impact of cultural and religious perspectives on approaches to LLST. Understanding and respecting the cultural and religious perspectives of patients and surrogates is essential to protecting patient autonomy and advancing goal-concordant care during critical moments of medical decision-making involving patients with DoC.

Clinical Course after End-of-Life Decisions on a Neurosurgical Ward: Much to Learn and Improve

BACKGROUND

 End-of-life (EoL) decisions are routine in neurosurgical care due to frequent devastating and life-threatening diagnoses. Advance directives, discussions with patients' relatives, and evaluation of the alleged will of the patient play an increasing important role in clinical decision-making. Institutional standards, ethical values, different ethnical backgrounds, and individual physician's experiences influence clinical judgments and decisions. We hypothesize that the implementation of palliative care in neurosurgical wards needs optimization. The aim of this study is to identify possible sources of error and to share our experiences.

METHODS

 This is a retrospective observational analysis. One hundred and sixty-eight patients who died on a regular neurosurgical ward between 2014 and 2019 were included. Medical reports were analyzed in detail. A differentiation between consistent and nonconsistent palliation was made, with consistent palliative care consisting of discontinuation of medication that was no longer indicated, administration of medication for symptom control, and consequent discontinuation of nutrition and fluid substitution that went beyond satisfying hunger or thirst.

RESULTS

 EoL decisions were made in 127 (84.1%) of all 168 cases; 100 patients were included in our analysis. Of these patients, only 24 had an advance directive, and the relatives were included in the communication about the therapy goals in 71 cases. Discontinuation of medication that is not for symptom control was performed in 63 patients, food withdrawal in 66 patients, and fluid substitution that went beyond the quenching of thirst was withdrawn in 27 patients. Thus, consistent palliative care was realized in 25% of all patients. The mean duration from the EoL decision until death was 2.1 days (range: 0-20 days). If a consistent palliative care was carried out, patients survived significantly shorter (nonconsistent palliative care: 2.4 days; range: 0-10 days vs. consistent palliative care: 1.2 days; range: 0-4 days; p = 0.008).

CONCLUSIONS

 The therapy goal should be thoroughly considered and determined at an early stage. If an EoL decision is reached, consistent palliative care should be carried out in order to limit suffering of moribund patients.

Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

IMPORTANCE

End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time.

OBJECTIVE

To determine the changes in end-of-life practices in European ICUs after 16 years.

DESIGN, SETTING, AND PARTICIPANTS

Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision.

EXPOSURES

Comparison between the 1999-2000 cohort vs 2015-2016 cohort.

MAIN OUTCOMES AND MEASURES

End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists.

RESULTS

Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001).

CONCLUSIONS AND RELEVANCE

Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.

Withholding Treatment From the Dying Patient: The Influence of Medical School on Students' Attitudes

PURPOSE

To determine motives and attitudes towards life-sustaining treatments (LSTs) by clinical and preclinical medical students.

METHODS

This was a scenario-based questionnaire that presented patients with a limited life expectancy. The survey was distributed among 455 medical students in preclinical and clinical years. Students were asked to rate their willingness to perform LSTs and rank the motives for doing so. The effect of medical education was then investigated after adjustment for age, gender, religion, religiosity, country of origin, and marital status.

RESULTS

Preclinical students had a significantly higher willingness to perform LSTs in all cases. This was observed in all treatments offered in cases of a metastatic oncologic patient and an otherwise healthy man after a traumatic brain injury (TBI). In the case of an elderly woman on long-term care, preclinical students had higher willingness to supply vasopressors but not perform an intubation, feed with a nasogastric tube, or treat with a continuous positive air-pressure ventilator. Both preclinical and clinical students had high willingness to perform resuscitation on a twelve-year-old boy with a TBI. Differences in motivation factors were also seen.

DISCUSSION

Preclinical students had a greater willingness to treat compared to clinical students in all cases and with most medical treatments offered. This is attributed mainly to changes along the medical curriculum. Changes in reasons for supplying LSTs were also documented.

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.