End-of-Life Practices in European Intensive Care Units

Abstract

HILE THE PRINCIPLE THAT dying patients should be treated with respect and compassionisbroadlyaccepted among health care professionals, medical practices for end-of-life care differ around the world. In the United States, medicine has moved from a paternalistic model to one that promotes autonomy and self-determination. 1,2 Patient expectations and preferences now help shape end-of-life practices, limiting the use of technologies that may prolong dying rather than facilitate recovery. 1,2 In Europe, patient-physician relationships are still somewhat paternalistic. 3-5 Different cultures and countries deal in diverse ways with the ethical dilemmas arising as a consequence of the wider availability of life-sustaining therapies. 3,4,6 Some have not adopted the Western emphasis on patient autonomy or methods of terminating life support. 3,4,6 In the past, patients died in intensive care units (ICUs) despite ongoing aggressive therapy. 7 Theoretical discussions 7 and attitudes of critical care Author Affiliations and the members of the Ethicus Study Group are listed at the end of this article.

Increased nonbeneficial care in patients spending their birthday in the ICU

“…Most ICU deaths follow decisions to forgo life-sustaining treatments (DFLSTs) [1][2][3][4][5]. DFLSTs are usually taken within 3 days after ICU admission, and the patient usually dies within the next 24 h [4].…”

“…DFLSTs are usually taken within 3 days after ICU admission, and the patient usually dies within the next 24 h [4]. Among patients discharged alive from the ICU, those who had DFLSTs taken in the ICU are less likely to survive to hospital discharge than are patients without such decisions [6].…”

“…These biases may account for considerable practice differences that cannot be explained by routinely collected information. Sources of bias may be patient related (e.g., patient unwilling to receive life support or be dependent on vasopressors), family related (e.g., cultural factors, religion, and religiosity [4,14,15]), and clinician related (e.g., gender, role, specialty, and time working in ICUs [16][17][18][19][20]). In addition, treatments are more likely to be withdrawn if they are expensive or scarce or if they support noniatrogenic events.…”

“…In addition, treatments are more likely to be withdrawn if they are expensive or scarce or if they support noniatrogenic events. Last, discrepancies have been reported across countries in the incidence of death after DFLSTs, characteristics of patients who die after DFLSTs, and weight given to the patient's and family's opinion [4,7,8]. In addition to cultural specificities, legislation may substantially affect practices regarding end-of-life decisions [2,12,16,[21][22][23].…”

“…End-of-life decisions were made in 22% and 24% of cases and controls, respectively. However, these decisions were made later in the cases than in the controls (18 versus 9 [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] days). Conclusions: Our finding that patients who spent their birthday in the ICU received a higher intensity of lifesustaining care and had longer ICU stays but did not have significantly different mortality rates compared with the controls suggests the use of nonbeneficial interventions.…”