Policies of withholding and withdrawal of life-sustaining treatment in critically ill patients on cardiac intensive care units in Germany: a national survey

Schimmer, Christoph; Gorski, Armin; Özkur, M.; Sommer, Sebastian; Hamouda, K.; Hain, Johannes; Aleksić, Ivan; Leyh, Rainer

doi:10.1093/icvts/ivr119

Cited by 15 publications

(18 citation statements)

References 25 publications

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“…A summary of all included articles and their quality assessments are shown in (see Tables 1 , 2 , and 3 ). In total, eight articles were assessed as having either moderate-to-high or high quality, eight articles were assessed as having moderate quality, four articles were assessed as having low-to-moderate quality, and four articles were assessed as having low quality (reference [ 33 , 34 , 38 , 40 ]) (see additional file 2 ) .…”

Section: Resultsmentioning

confidence: 99%

Factors influencing the integration of a palliative approach in intensive care units: a systematic mixed-methods review

et al. 2020

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Background While a palliative approach is generally perceived to be an integral part of the intensive care unit (ICU), the provision of palliative care in this setting is challenging. This review aims to identify factors (barriers and facilitators) influencing a palliative approach in intensive care settings, as perceived by health care professionals. Method A systematic mixed-methods review was conducted. Multiple electronic databases were used, and the following search terms were utilized: implementation, palliative care, and intensive care unit. In total, 1843 articles were screened, of which 24 met the research inclusion/exclusion criteria. A thematic synthesis method was used for both qualitative and quantitative studies. Results Four key prerequisite factors were identified: (a) organizational structure in facilitating policies, unappropriated resources, multi-disciplinary team involvement, and knowledge and skills; (b) work environment, including physical and psychosocial factors; (c) interpersonal factors/barriers, including family and patients’ involvement in communication and participation; and (d) decision-making, e.g., decision and transition, goal conflict, multidisciplinary team communication, and prognostication. Conclusion Factors hindering the integration of a palliative approach in an intensive care context constitute a complex interplay among organizational structure, the care environment and clinicians’ perceptions and attitudes. While patient and family involvement was identified as an important facilitator of palliative care, it was also recognized as a barrier for clinicians due to challenges in shared goal setting and communication.

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Section: Resultsmentioning

confidence: 99%

Factors influencing the integration of a palliative approach in intensive care units: a systematic mixed-methods review

et al. 2020

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“…(2012) [ 33 ] European countries (6 countries) To examine whether religion and religiosity are important to end-of-life decisions and patient autonomy in the ICU Structured questionnaires in 6 European countries, 143 ICUs 304 physicians 6 Schimmer et al . (2012) [ 34 ] Germany To determine the decision-making process of withholding and/or withdrawing of life-sustaining treatment in cardiac ICUs in Germany Questionnaire distributed to all heart surgery ICUs ( N = 79) in Germany 35 clinical directors, 25 senior ICU physicians 6 Kübler et al . (2011) [ 35 ] Poland To analyse the attitudes of ICU physicians regarding decisions to forgo life-sustaining treatment for adult ICU patients Survey 217 intensive care physicians working in ICUs in Poland 6 Weng et al .…”

Section: Resultsmentioning

confidence: 99%

“…Medium-strength evidence was found that physicians prefer their own ideas of what is in the best interest of the patient, focusing instead on clinical and technical parameters to decide on withholding or withdrawing therapy, and do not respect the wishes of the patient or the patient’s family to stop therapy, even when there is a living will [ 27 , 33 , 34 , 40 ]. Further, medium-strength evidence was found for the barrier that, even when the team confirms that treatment is futile and inappropriate, physicians follow the family’s wishes when the family wants to continue futile treatment out of concerns about legal action [ 16 , 26 , 36 , 39 , 42 ].…”

Section: Resultsmentioning

confidence: 99%

Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: a systematic review

2014

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IntroductionAlthough many terminally ill people are admitted to an intensive care unit (ICU) at the end of life, their care is often inadequate because of poor communication by physicians and lack of patient- and family-centred care. The aim of this systematic literature review was to describe physician-related barriers to adequate communication within the team and with patients and families, as well as barriers to patient- and family-centred decision-making, towards the end of life in the ICU. We base our discussion and evaluation on the quality indicators for end-of-life care in the ICU developed by the Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup.MethodFour electronic databases (MEDLINE, Embase, CINAHL and PsycINFO) were searched, using controlled vocabulary and free text words, for potentially relevant records published between 2003 and 2013 in English or Dutch. Studies were included if the authors reported on physician-related and physician-reported barriers to adequate communication and decision-making. Barriers were categorized as being related to physicians’ knowledge, physicians’ attitudes or physicians’ practice. Study quality was assessed using design-specific tools. Evidence for barriers was graded according to the quantity and quality of studies in which the barriers were reported.ResultsOf 2,191 potentially relevant records, 36 studies were withheld for data synthesis. We determined 90 barriers, of which 46 were related to physicians’ attitudes, 24 to physicians’ knowledge and 20 to physicians’ practice. Stronger evidence was found for physicians’ lack of communication training and skills, their attitudes towards death in the ICU, their focus on clinical parameters and their lack of confidence in their own judgment of their patient’s true condition.ConclusionsWe conclude that many physician-related barriers hinder adequate communication and shared decision-making in ICUs. Better physician education and palliative care guidelines are needed to enhance knowledge, attitudes and practice regarding end-of-life care. Patient-, family- and health care system–related barriers need to be examined.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0604-z) contains supplementary material, which is available to authorized users.

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“…Such difficulties arise, in part, because a family may be facing an unexpected poor prognosis associated with an acute illness or exacerbation and, in part, because the ICU orientation is one way of saving lives. In a study of policies of withholding and withdrawal of life-sustaining treatment in critically ill patients on cardiac ICUs, cranial computed tomography with poor prognosis, multiorgan failure, and failure of assist device therapy were the most frequently cited medical reasons for withholding or withdrawal of life-sustaining treatments, while poor expected quality of life, the patient's willingness to limit medical care, and the family's choice were the top ethical reasons [11]. Unfortunately, a considerable variation in the apparent willingness of consultants to make endof-life decisions has been reported, emphasizing the subjective nature of these decisions [6].…”

Section: Key Pointsmentioning

confidence: 99%

The anesthesiologist and end-of-life care

Mercadante

Giarratano

2012

Current Opinion in Anaesthesiology

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Anesthesiologists should be competent in all aspects of terminal care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. More research is needed to provide models which should be spread in the scientific community to afford this difficult task.

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Policies of withholding and withdrawal of life-sustaining treatment in critically ill patients on cardiac intensive care units in Germany: a national survey

Abstract: This survey is a step towards creating standards of end-of-life care in cardiac ICUs, which may contribute to build consensus and avoid conflicts among caregivers, patients and families at each step of the decision-making process.

Cited by 15 publications

References 25 publications

Factors influencing the integration of a palliative approach in intensive care units: a systematic mixed-methods review

Factors influencing the integration of a palliative approach in intensive care units: a systematic mixed-methods review

Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: a systematic review

The anesthesiologist and end-of-life care

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