End-of-life practices in European intensive care units: the Ethicus Study

The views of patients and relatives of what makes a good intensivist: a European survey

OBJECTIVE

This study examined the views of adult patients and relatives about desirable characteristics of specialists in intensive care medicine (ICM) to incorporate these into an international competency-based training programme, CoBaTrICE.

DESIGN

Convenience sample of patients and relatives administered after discharge from 70 participating ICUs in eight European countries (1,398 evaluable responses). The structured questionnaire included 21 characteristics of medical competence categorised as 'medical knowledge and skills', 'communication with patients', and 'communication with relatives'. It was available in the national languages of the countries involved. Questions were rated by respondents for importance using a four-point Likert scale. Responses to open questions were also invited.

RESULTS

Most characteristics were highly rated, with priority given to medical knowledge and skills. Women were more likely to emphasise communication skills. There were no consistent regional differences. Free-text responses welcomed the opportunity to participate.

CONCLUSIONS

Patients and relatives with experience of intensive care in different European countries share similar views on the importance of knowledge, skills, decision making and communication in the training of intensive care specialists. These generic patient-centred components of training have been incorporated into the international competency-based ICM training programme, CoBaTrICE.

How qualitative research can contribute to research in the intensive care unit

A qualitative research design can provide unique contributions to research in the intensive care unit. Qualitative research includes the entire process of research: the methodology (conceptualization of the research question, choosing the appropriate qualitative strategy, designing the protocol), methods (conducting the research using qualitative methods within the chosen qualitative strategy, analysis of the data, verification of the findings), and writing the narrative. The researcher is the instrument and the data are the participants' words and experiences that are collected and coded to present experiences, discover themes, or build theories. A number of strategies are available to conduct qualitative research and include grounded theory, phenomenology, case study, and ethnography. Qualitative methods can be used to understand complex phenomena that do not lend themselves to quantitative methods of formal hypothesis testing. Qualitative research may be used to gain insights about organizational and cultural issues within the intensive care unit and to improve our understanding of social interaction and processes of health care delivery. In this article, we outline the rationale for, and approaches to, using qualitative research to inform critical care issues. We provide an overview of qualitative methods available and how they can be used alone or in concert with quantitative methods. To illustrate how our understanding of social phenomena such as patient safety and behavior change has been enhanced we use recent qualitative studies in acute care medicine.

Care for dying patients – German legislation

Caring for dying patients appears to be one of the most difficult challenges in modern medicine. Apart from respective medical standards, such care is influenced by legal stipulations, economic resources, societal values, and ethical principles. In Germany, legal provisions prohibit actively hastening a patient's death. Although passive and indirect means of assistance to die are permitted for terminally ill patients, they appear to be implemented only with hesitation. Probably, the authority of advance directives needs further clarification. More importantly, however, physicians' deficits in knowledge as well as their conceptual and psycho-emotional barriers need comprehensive improvement in order to foster end-of-life care.

The importance of religious affiliation and culture on end-of-life decisions in European intensive care units

OBJECTIVE

To determine the influence of religious affiliation and culture on end-of-life decisions in European intensive care units (ICUs).

DESIGN AND SETTING

A prospective, observational study of European ICUs was performed on consecutive patients with any limitation of therapy. Prospectively defined end-of-life practices in 37 ICUs in 17 European countries studied from 1 January 1999 to 30 June 2000 were compared for frequencies, patterns, timing, and communication by religious affiliation of physicians and patients and regions.

RESULTS

Of the 31,417 patients 3,086 had limitations. Withholding occurred more often than withdrawing if the physician was Jewish (81%), Greek Orthodox (78%), or Moslem (63%). Withdrawing occurred more often for physicians who were Catholic (53%), Protestant (49%), or had no religious affiliation (47%). End-of-life decisions differed for physicians between regions and who had any religious affiliation vs. no religious affiliation in all three geographical regions. Median time from ICU admission to first limitation of therapy was 3.2 days but varied by religious affiliation; from 1.6 days for Protestant to 7.6 days for Greek Orthodox physicians. Median times from limitations to death also varied by physician's religious affiliation. Decisions were discussed with the families more often if the physician was Protestant (80%), Catholic (70%), had no religious affiliation (66%) or was Jewish (63%).

CONCLUSIONS

Significant differences associated with religious affiliation and culture were observed for the type of end of life decision, the times to therapy limitation and death, and discussion of decisions with patient families.

Variation in length of intensive care unit stay after cardiac arrest: where you are is as important as who you are

OBJECTIVE

To determine whether hospital site is independently associated with length of intensive care unit (ICU) stay in those patients who die in hospital after experiencing a cardiac arrest.

DESIGN

Retrospective cohort study.

SETTING

Thirty-one Canadian ICUs, all but one being members of the Critical Care Research Network.

PATIENTS

All patients admitted to these ICUs after resuscitation from a cardiac arrest.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Retrospective analysis of prospectively collected clinical data. Using gamma regression with ICU length of stay as the dependent variable, we found the following variables to be independently associated with ICU length of stay: age, gender, Acute Physiology and Chronic Health Evaluation II score, Glasgow Coma Scale score, hospital size, and hospital site.

CONCLUSIONS

In this cohort of patients admitted to ICU after cardiac arrest, hospital site was strongly associated with ICU length of stay after controlling for patient-specific factors. Variation in processes of care among ICUs may point to opportunities for improvement.

Assessing contemporary intensive care unit outcome: an updated Mortality Probability Admission Model (MPM0-III)

OBJECTIVE

To update the Mortality Probability Model at intensive care unit (ICU) admission (MPM0-II) using contemporary data.

DESIGN

Retrospective analysis of data from 124,855 patients admitted to 135 ICUs at 98 hospitals participating in Project IMPACT between 2001 and 2004. Independent variables considered were 15 MPM0-II variables, time before ICU admission, and code status. Univariate analysis and multivariate logistic regression were used to identify risk factors associated with hospital mortality.

SETTING

One hundred thirty-five ICUs at 98 hospitals.

PATIENTS

Patients in the Project IMPACT database eligible for MPM0-II scoring.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Hospital mortality rate in the current data set was 13.8% vs. 20.8% in the MPM0-II cohort. All MPM0-II variables remained associated with mortality. Clinical conditions with high relative risks in MPM0-II also had high relative risks in MPM0-III. Gastrointestinal bleeding is now associated with lower mortality risk. Two factors have been added to MPM0-III: "full code" resuscitation status at ICU admission, and "zero factor" (absence of all MPM0-II risk factors except age). Seven two-way interactions between MPM0-II variables and age were included and reflect the declining marginal contribution of acute and chronic medical conditions to mortality risk with increasing age. Lead time before ICU admission and pre-ICU location influenced individual outcomes but did not improve model discrimination or calibration. MPM0-III calibrates well by graphic comparison of actual vs. expected mortality, overall standardized mortality ratio (1.018; 95% confidence interval, 0.996-1.040) and a low Hosmer-Lemeshow goodness-of-fit statistic (11.62; p = .31). The area under the receiver operating characteristic curve was 0.823.

CONCLUSIONS

MPM0-II risk factors remain relevant in predicting ICU outcome, but the 1993 model significantly overpredicts mortality in contemporary practice. With the advantage of a much larger sample size and the addition of new variables and interaction effects, MPM0-III provides more accurate comparisons of actual vs. expected ICU outcomes.

Factors influencing completion of advanced directives in hospitalized patients

AIM

A cross-sectional, descriptive study to describe characteristics and other factors that influenced the decision by hospitalized patients in the East Texas area to formulate an advanced directive (AD).

FINDINGS

Spouses, family members and sense of spirituality were the strongest influential factors for completion of an AD. Most learned about ADs from family, friends, personal attorneys, and others, while less than a quarter of the sample learned about ADs from health care providers. Not wanting to be a burden on their family was the major reason cited for completing an AD.

CONCLUSIONS

Health care provider roles are vague in terms of responsibility for AD discussion and education. Further exploration of the attitudes, knowledge and practices concerning ADs of nurses and primary health care providers is recommended to provide focal points for future research in order to facilitate peace of mind for patients and families at end-of-life.

Optimizing neurologic prognosis after cardiac arrest

Neurologic disability is a feared outcome of resuscitation from cardiac arrest. The study by Rech and colleagues in the previous issue of Critical Care describes the use of neuron-specific enolase to inform an early prognosis in patients who survived in-hospital cardiac arrest. In their study 'none of the patients had a DNR order and there was no limitation of life support.' As a result, 10% of patients remained in a vegetative state at 6 months, a higher percentage than in other recent studies. The existence of a population of patients in which all are fully supported without withholding care or withdrawal of care may represent an important research opportunity. High neuron-specific enolase levels have been reported in patients that awoke and seem to occur in studies with a higher percentage of patients in a vegetative state at follow-up (more uniform support). If a comprehensive set of clinical, electrophysiological, biochemical and imaging measures could be obtained in a uniform manner in a cohort of patients without limitations in care, a more objective set of comprehensive prognostic indicators could be obtained. A focused international consortium is called for.

Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate

OBJECTIVE

To explore registered nurses' and attending physicians' perspectives on caring for dying patients in intensive care units (ICUs), with particular attention to the relationships among moral distress, ethical climate, physician/nurse collaboration, and satisfaction with quality of care.

DESIGN

Descriptive pilot study using a survey design.

SETTING

Fourteen ICUs in two institutions in different regions of Virginia.

SUBJECTS

Twenty-nine attending physicians who admitted patients to the ICUs and 196 registered nurses engaged in direct patient care.

INTERVENTIONS

Survey questionnaire.

MEASUREMENTS AND MAIN RESULTS

At the first site, registered nurses reported lower collaboration (p<.001), higher moral distress (p<.001), a more negative ethical environment (p<.001), and less satisfaction with quality of care (p=.005) than did attending physicians. The highest moral distress situations for both registered nurses and physicians involved those situations in which caregivers felt pressured to continue unwarranted aggressive treatment. Nurses perceived distressing situations occurring more frequently than did physicians. At the second site, 45% of the registered nurses surveyed reported having left or considered leaving a position because of moral distress. For physicians, collaboration related to satisfaction with quality of care (p<.001) and ethical environment (p=.004); for nurses, collaboration was related to satisfaction (p<.001) and ethical climate (p<.001) at both sites and negatively related to moral distress at site 2 (p=.05). Overall, registered nurses with higher moral distress scores had lower satisfaction with quality of care (p<.001), lower perception of ethical environment (p<.001), and lower perception of collaboration (p<.001).

CONCLUSIONS

Registered nurses experienced more moral distress and lower collaboration than physicians, they perceived their ethical environment as more negative, and they were less satisfied with the quality of care provided on their units than were physicians. Provider assessments of quality of care were strongly related to perception of collaboration. Improving the ethical climate in ICUs through explicit discussions of moral distress, recognition of differences in nurse/physician values, and improving collaboration may mitigate frustration arising from differences in perspective.

End-of-life family conferences: rooted in the evidence

Critical care clinicians no longer consider family members as visitors in the intensive care unit. Family-centered care has emerged from the results of qualitative and quantitative studies evaluating the specific needs of families of patients dying in the intensive care unit. In addition, interventional studies have established that intensive and proactive communication empowers family members of dying patients, helping them to share in discussions and decisions, if they so wish. In addition to intensive communication, interventional studies have highlighted the role of nurses, social workers, and palliative care teams in reducing family burden, avoiding futile life-sustaining therapies, and providing effective comfort care. End-of-life family conferences are formal, structured meetings between intensivists and family members. Guidelines for organizing these conferences take into account the specific needs of families, including reassurance that the patient's symptoms will be adequately managed; honest clear information about the patient's condition and treatment; a willingness on the part of physicians to listen and respond to family members and to address their emotions; attention to patient preferences; clear explanations about surrogate decision making; and continuous, compassionate, and technically proficient attention to the patient's needs until death occurs. Means of improving end-of-life care have been identified in epidemiologic and interventional studies. End-of-life family conferences constitute the keystone around which excellent end-of-life care can be built.

Ethical considerations at the end of life in the intensive care unit

Intensive care units (ICUs) confront the healthcare system with end-of-life situations and ethical dilemmas surrounding death. It is necessary for all providers who treat dying patients to have a working knowledge of the philosophical principles that are fundamental to biomedical ethics. Those principles, however, are insufficient for compassionate care. To function well in the intensive care unit, one also must appreciate the behaviors that surround mortality. Human conduct is not predicated solely on rules; complex, unpredictable interactions are the norm. Palliative care, moving forward as a discipline, will become the perfect complement to intensive medical care, rather than being seen as an embodiment of its failures. We need to be as aggressive about respecting patient dignity as we are about using the technology that is central to health care. This article will outline end-of-life ethical principles, explore the sociology that influences human interactions in intensive care units, and show how palliative care should guide behaviors to improve how we deal with death.

Understanding and changing attitudes toward withdrawal and withholding of life support in the intensive care unit

A careful examination of our attitudes toward end-of-life care is critical to our understanding of where change is needed to improve patient outcomes. The objectives of our narrative review are 1) to review why the intensive care unit setting presents particular challenges for the delivery of optimal end-of-life care, 2) to outline how four different research methods can provide insights into our understanding of attitudes about withdrawal of life support, and 3) to suggest seven different approaches to changing prevailing attitudes toward withdrawal of life support in the intensive care unit. To better understand attitudes about end-of-life care in general and withdrawal of life support in particular, we reviewed four different sources of data: 1) decision support tools, 2) qualitative research, 3) surveys, and 4) observational studies. Understanding these attitudes offers valuable insights about strategies that may help to improve the care of dying patients and their families. There are several ways to change attitudes; the approaches we reviewed are 1) promoting social change professionally, 2) legitimizing end-of-life research, 3) determining what families of dying patients need, 4) initiating quality improvement locally, 5) evaluating the benefits and harms of new initiatives, 6) modeling quality end-of-life care for future clinicians, and 7) using narratives. Attitudes toward end-of-life care are influenced by many factors and change slowly. Our attitudes have social and personal origins; they are grounded in values that are collective and community based. Different research methods provide insights into attitudes toward death in the intensive care unit and withdrawal of life support in particular. Understanding these attitudes may offer valuable insights about strategies that should help improve the care for dying patients and their families.

Relationship of neonatologists' end-of-life decisions to their personal fear of death

OBJECTIVE

To study the relationship of Australian and New Zealand (ANZ) neonatologists' personal fear of death to their forgoing life-sustaining treatment and hastening death in newborns destined for severe disability and newborns for whom further treatment is considered non-beneficial or overly burdensome.

DESIGN

A self-report questionnaire survey of ANZ neonatologists.

SETTING

Neonatologists registered in the 2004 ANZ Directory of Neonatal Intensive Care Units.

PARTICIPANTS

78 of 138 (56%) neonatologists who responded to the study questionnaire.

MAIN OUTCOME MEASURES

Between-group differences in the Multidimensional Fear of Death Scale.

RESULTS

In newborns for whom further treatment was deemed futile, 73 neonatologists reported their attitude to hastening death as follows: 23 preferred to hasten death by withdrawing minimal treatment, 35 preferred to hasten death with analgesia-sedation, and 15 reported that hastening death was unacceptable. Analysis of variance showed a statistically significant difference between the three groups regarding fear of the dying process (F = 3.78, p = 0.028), fear of premature death (F = 3.28, p = 0.044) and fear of being destroyed (F = 3.20, p = 0.047). Post hoc comparisons showed that neonatologists who reported that hastening death was unacceptable compared with neonatologists who preferred to hasten death with analgesia-sedation had significantly less fear of the dying process and fear of premature death, and significantly more fear of being destroyed.

CONCLUSIONS

ANZ neonatologists' personal fear of death and their attitude to hastening death when further treatment is considered futile are significantly related. Neonatologists' fear of death may influence their end-of-life decisions.

Ethics and law in the intensive care unit

Intensive Care Medicine epitomises the difficulties inherent in modern medicine. In this chapter we examine some key medicolegal and ethical areas that are evolving. The principles of autonomy and consent are well established, but developments in UK caselaw have shown that the courts may be moving away from their traditional deference of the medical profession. We examine some recent cases and discuss the impact that these cases may have on practice in Intensive Care.

Israeli critical care nurses' attitudes toward physician-assisted dying

BACKGROUND

Within critical care, end-of life decisions are common, including hastening of the dying process. One type of hastening the dying process is physician-assisted dying (PAD).

OBJECTIVES

The purpose of this study was to determine Israeli critical care nurses' attitudes and practices toward PAD.

METHODS

A convenience sample of 71 intensive care unit nurses were asked to fill out a modified critical care, Hebrew version of the Nurse's Attitudes Regarding Physician-Assisted Dying Questionnaire. Subjects were also asked whether they were requested or whether they performed actions to hasten the dying process.

RESULTS

The majority of nurses supported PAD. However, only 10% of the respondents agreed to participate when PAD was to be administered by the nurse. Some nurses were asked by patients (12.7%) and/or by families (7.0%) to hasten the dying process. No nurse reported administering any lethal treatment. No significant differences in responses to the vignettes were found based on gender, marital status, place of birth or parents' place of birth, religion, age, type of education, having taken a post-basic course, years of general or intensive care unit nursing experience, or type of intensive care unit. However, significant differences were found in four vignettes based on level of self-perceived religiosity.

CONCLUSION

The findings demonstrated that the Israeli critical care nurses sampled tended to agree with the concept of PAD but were unlikely to agree to having a more active role in hastening the dying process. This particular finding was true especially among those nurses who considered themselves more religious.

A communication strategy and brochure for relatives of patients dying in the ICU

BACKGROUND

There is a need for close communication with relatives of patients dying in the intensive care unit (ICU). We evaluated a format that included a proactive end-of-life conference and a brochure to see whether it could lessen the effects of bereavement.

METHODS

Family members of 126 patients dying in 22 ICUs in France were randomly assigned to the intervention format or to the customary end-of-life conference. Participants were interviewed by telephone 90 days after the death with the use of the Impact of Event Scale (IES; scores range from 0, indicating no symptoms, to 75, indicating severe symptoms related to post-traumatic stress disorder [PTSD]) and the Hospital Anxiety and Depression Scale (HADS; subscale scores range from 0, indicating no distress, to 21, indicating maximum distress).

RESULTS

Participants in the intervention group had longer conferences than those in the control group (median, 30 minutes [interquartile range, 19 to 45] vs. 20 minutes [interquartile range, 15 to 30]; P<0.001) and spent more of the time talking (median, 14 minutes [interquartile range, 8 to 20] vs. 5 minutes [interquartile range, 5 to 10]). On day 90, the 56 participants in the intervention group who responded to the telephone interview had a significantly lower median IES score than the 52 participants in the control group (27 vs. 39, P=0.02) and a lower prevalence of PTSD-related symptoms (45% vs. 69%, P=0.01). The median HADS score was also lower in the intervention group (11, vs. 17 in the control group; P=0.004), and symptoms of both anxiety and depression were less prevalent (anxiety, 45% vs. 67%; P=0.02; depression, 29% vs. 56%; P=0.003).

CONCLUSIONS

Providing relatives of patients who are dying in the ICU with a brochure on bereavement and using a proactive communication strategy that includes longer conferences and more time for family members to talk may lessen the burden of bereavement. (ClinicalTrials.gov number, NCT00331877.)

Attitudes of European physicians, nurses, patients, and families regarding end-of-life decisions: the ETHICATT study

OBJECTIVE

To evaluate attitudes of Europeans regarding end-of-life decisions.

DESIGN AND SETTING

Responses to a questionnaire by physicians and nurses working in ICUs, patients who survived ICU, and families of ICU patients in six European countries were compared for attitudes regarding quality and value of life, ICU treatments, active euthanasia, and place of treatment.

MEASUREMENTS AND RESULTS

Questionnaires were distributed to 4,389 individuals and completed by 1,899 (43%). Physicians (88%) and nurses (87%) found quality of life more important and value of life less important in their decisions for themselves than patients (51%) and families (63%). If diagnosed with a terminal illness, health professionals wanted fewer ICU admissions, uses of CPR, and ventilators (21%, 8%, 10%, respectively) than patients and families (58%, 49%, 44%, respectively). More physicians (79%) and nurses (61%) than patients (58%) and families (48%) preferred being home or in a hospice if they had a terminal illness with only a short time to live.

CONCLUSIONS

Quality of life was more important for physicians and nurses than patients and families. More medical professionals want fewer ICU treatments and prefer being home or in a hospice for a terminal illness than patients and families.

Contradictions and communication strategies during end-of-life decision making in the intensive care unit

PURPOSE

The aim of this study was to identify inherent tensions that arose during family conferences in the intensive care unit, and the communication strategies clinicians used in response.

MATERIALS AND METHODS

We identified 51 clinician-family conferences in the intensive care unit from 4 hospitals in which the attending physician believed discussion of withdrawing life-sustaining treatments or delivery of bad news would occur. The communication between clinicians and family members was analyzed using a dialectic perspective.

RESULTS

The tension of choosing whether to "let the patient die now" versus to "not let the patient die now" was the central contradiction within the conferences. Under this overriding theme were 5 categories: killing or allowing to die; death as a benefit or a burden; honoring the patient's wishes or following the family's wishes; weighing contradictory versions of the patient's wishes; and choosing an individual family member as decision maker or the family as a unit as decision maker. In response to these contradictions, clinicians used 2 clusters of communication strategies: decision-centered strategies and information-seeking strategies.

CONCLUSIONS

This study offered insights into end-of-life decision making, prompting clinicians to be conscious of the contradictions that arise and to use specific strategies to address these contradictions in their communication with families.

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.

The logistic organ dysfunction score as a tool for making ethical decisions

PURPOSE

We examined whether the change of the logistic organ dysfunction score (LOD) between the first and the fourth day in the intensive care unit (ICU) could be predictive of death in the ICU. The LOD could then be used to help make decisions concerning therapeutic limitations (TL).

METHODS

One hundred fifty-four patients were included. Exclusion criteria were: discharge from the ICU or TL before the 72nd hr. Ninety-three patients remained for evaluation. The LOD was calculated on the day of admission (LOD1) and between the 72nd and 96th hr (LOD4). The DeltaLOD = LOD4-LOD1 index was calculated for survivors and non-survivors; sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.

RESULTS

Sixteen patients died in the ICU, they had a higher DeltaLOD (0 vs -2; P = 0.0046) than the survivors. After logistic regression, a high DeltaLOD was associated with a higher risk of death in the ICU independent of the initial severity of disease. The PPV concerning death in the ICU was 0.66 for a DeltaLOD > or = 4 cut-off. The NPV was 0.89 for a cut-off of > or = 1.

CONCLUSION

DeltaLOD appears to be a predictor of death in the ICU, independent of the initial severity of disease. The PPV is not high enough to assist with making individual TL decisions. The NPV can help to identify patients at low risk of death. The DeltaLOD deserves to be evaluated in a population exhibiting greater severity of disease.

Is there a role for inhaled nitric oxide as a rescue therapy in respiratory failure associated with hematologic malignancies?

Inhaled nitric oxide has been demonstrated to improve oxygenation in critically ill patients requiring mechanical ventilation. We therefore performed a retrospective review to determine the outcome of patients with hematological malignancies and acute respiratory failure who received inhaled nitric oxide (INO) in a multidisciplinary intensive care unit of a single tertiary referral medical center. Thirteen patients with hematological malignancies who required endotracheal intubation and mechanical ventilation and received INO for acute respiratory failure between January 1998 and December 2002 were identified. Mean +/- standard deviation (SD) age was 47.6 (+/-13.2) years. The mean +/- SD Acute Physiology and Chronic Health Evaluation (APACHE) III score on the day of ICU admission was 94.1 +/- 33.7 with a mean (SD) predicted probability of ICU death of 42.4% (+/-28.6). Mean APACHE III score on the day of initiating INO was 107.6 (+/-34.4) with a predicted mortality in the intensive care unit of 72.7% (+/-23.3). Mean PaO(2) to FiO(2) (PF) ratios (+/-SD) prior to, and immediately after, the initiation of INO were 62.6 (+/-28.2) and 111 (+/-65.1), respectively (P < 0.001). The median duration of INO therapy was 41.8 h (interquartile range, 6.3-98.2). Patients with hematological malignancies and acute respiratory failure to whom INO was administered had clinical deterioration since ICU admission. Despite a marked initial improvement in arterial oxygen tension, all patients ultimately died in the intensive care unit, 8 of them within 48 h of initiating INO. Therefore, despite initial improvement in oxygenation, we did not observe any survival benefit to INO in this setting.

[Ethical attitudes in Spanish pediatric critical care units]

OBJECTIVES

To assess physicians' awareness and experience of ethical problems that arise when dealing with critically ill children in pediatric intensive care units (PICUs).

MATERIAL AND METHODS

Questionnaires containing 20 questions about ethical dilemmas and attitudes related to the care of children admitted to PICUs were mailed to 43 PICUs in Spain.

RESULTS

Ninety-five responses corresponding to 24 residents and 71 attending physicians were received from 21 PICUs. The occurrence of ethical dilemmas in the PICU was recognized by 96.8 % of the respondents. The most frequent method of solving these problems was through medical consensus (80 %), while family participation in the decision making process was highly variable. A total of 95.8 % of respondents stated that decisions to limit therapy were made in their PICU, although only one third of these decisions were written in the medical record. The most frequent form of therapeutic limitation was the do not resuscitate order. One third (32.6 %) of participants considered there were ethical differences between withdrawal and withholding of treatment. Attending physicians had greater experience of therapeutic limitation than did residents, but their opinions on the subject were similar.

CONCLUSIONS

Ethical dilemmas are common in the PICU. In this setting, decisions about limitation of therapy are frequent, although many physicians admit to not being clear on this issue or on other aspects of clinical ethics. Family members' participation in the decision making process is insufficient in Spanish PICUs.

Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers

OBJECTIVE

Many intensive care unit (ICU) physicians have withdrawn life-support from a patient who lacked decision-making capacity and a surrogate decision-maker, yet little is known about the decision-making practices for these patients. We sought to determine how often such patients are admitted to the ICU of a metropolitan hospital and how end-of-life decisions are made for them.

DESIGN

Prospective, observational cohort study.

PATIENTS AND SETTING

Consecutive adult patients admitted to the medical ICU of a metropolitan West Coast hospital during a 7-month period in 2003 to 2004.

MEASUREMENTS

Attending physicians completed a questionnaire about the decision-making process for each patient for whom they considered limiting life-support who lacked decisional capacity and a legally recognized surrogate decision-maker.

MAIN RESULTS

Of the 303 patients admitted during the study period, 49 (16%; 95% confidence interval [CI], 12-21%) lacked decision-making capacity and a surrogate during the entire ICU stay. Compared with all other ICU patients, these patients were more likely to be male (88% vs. 69%; p = .002), white (42% vs. 23%; p = .028), and > or =65 yrs old (29% vs. 13%; p = .007). Physicians considered withholding or withdrawing treatment from 37% (18) of the 49 patients who lacked both decision-making capacity and a surrogate decision-maker. For 56% (10) of these 18 patients, the opinion of another attending physician was obtained; for 33% (6 of 18), the ICU team made the decision independently, and for 11% (2 of 18), the input of the courts or the hospital ethics committee was obtained. Overall, 27% of deaths (13 of 49) during the study period were in incapacitated patients who lacked a surrogate (95% CI, 15-41%).

CONCLUSIONS

Sixteen percent of patients admitted to the medical ICU of this hospital lacked both decision-making capacity and a surrogate decision-maker. Decisions to limit life support were generally made by physicians without judicial or institutional review. Further research and debate are needed to develop optimal decision-making strategies for these difficult cases.

A critical discourse analysis of provision of end-of-life care in key UK critical care documents

This article highlights certain practical and professional difficulties in providing end-of-life (EOL) care for patients in critical care units and explores discourses arising from guidelines for critical care services.

BACKGROUND

A significant number of patients die in critical care after decisions to withdraw or withhold treatment. Guidelines for provision of critical care suggest, wherever possible, moving patients out of critical care at the EOL. This may not necessarily be conducive to a 'good death' for patients or their loved ones. There is a moral responsibility for both nurses and doctors to ensure that decision-making around EOL issues is sensitively implemented, that decisions about care includes families, patients when able, nurses and doctors, and that good EOL care is provided.

METHODS

A critical discourse analysis (CDA) of four key UK critical care documents published since 1996.

FINDINGS AND RECOMMENDATIONS

The key documents give little clear guidance about how to provide EOL care in critical care. Discourses include the power dynamic in critical care between professions, families and patients, and how this impacts on provision of EOL care. Difficulties encountered include dilemmas at discharge and paternalism in decision-making. The technological environment can act as a barrier to good EOL care, and critical care nurses are at risk of assuming the dominant medical model of care. Nurses, however, are in a prime position to ensure that decision-making is an inclusive process, patient needs are paramount, the practical aspects of withdrawal lead to a smooth transition in goals of care and that comfort measures are implemented.

"Euthanasia": A confusing term, abused under the Nazi regime and misused in present end-of-life debate

BACKGROUND

Legal provisions in The Netherlands and Belgium currently allow physicians to actively end a patient's life at his or her request under certain conditions. The term that is used for this is "euthanasia."

DISCUSSION

The same term, "euthanasia," was used in Germany during the Nazi regime for a program of cleansing the "German nation" in which untold thousands of persons were denied human empathy or medical care and were thereby condemned to death. The medical profession played a leading role in the planning, administration, and supervision of this "euthanasia" program, with a large proportion of German physicians proactively shirking all moral responsibility and ultimately paving the way for the Holocaust.

CONCLUSION

The term "euthanasia" was so abused during the Nazi regime as a camouflage word for murder of selected subpopulations with the willing participation of physicians, we believe that, regardless of the benevolent goals of current euthanasia practices, for historical reasons the term "euthanasia" must not be used with regards to current end-of-life care.

Do-not-resuscitate decisions in six European countries*

OBJECTIVE

To study and compare the incidence and main background characteristics of do-not-resuscitate (DNR) decision making in six European countries.

DESIGN

Retrospective.

SETTING

We studied DNR decisions simultaneously in Belgium (Flanders), Denmark, Italy (four regions), the Netherlands, Sweden, and Switzerland (German-speaking part). In each country, random samples of death certificates were drawn from death registries to which all deaths are reported. The deaths occurred between June 2001 and February 2002.

PARTICIPANTS

Reporting physicians received a mailed questionnaire about the medical decision making that had preceded death. The response percentage was 75% for the Netherlands, 67% for Switzerland, 62% for Denmark, 61% for Sweden, 59% for Belgium, and 44% for Italy. The total number of deaths studied was 20,480.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Measurements were frequency of DNR decisions, both individual and institutional, and patient involvement. Before death, an individual DNR decision was made in about 50-60% of all nonsudden deaths (Switzerland 73%, Italy 16%). The frequency of institutional decisions was highest in Sweden (22%) and Italy (17%) and lowest in Belgium (5%). DNR decisions are discussed with competent patients in 10-84% of cases. In the Netherlands patient involvement rose from 53% in 1990 to 84% in 2001. In case of incompetent patients, physicians bypassed relatives in 5-37% of cases.

CONCLUSIONS

Except in Italy, DNR decisions are a common phenomenon in these six countries. Most of these decisions are individual, but institutional decisions occur frequently as well. In most countries, the involvement of patients in DNR decision making can be improved.

Understanding disparities in aggressive care preferences between patients with terminal illness and their family members

We examined the factors associated with the disparity in aggressive care preferences between patients with terminal cancer and their family members. Two hundred forty-four consecutive pairs recruited from three university hospitals participated in this study. Each pair completed questionnaires that measured two major aggressive care preferences-admission to the intensive care unit (ICU) and the use of cardiopulmonary resuscitation (CPR). Sixty-eight percent of patients and their family members were in agreement regarding admission to the ICU and 71% agreed regarding CPR. Regarding admission to the ICU, younger, unmarried patients and patients who preferred to die in an institution were more likely to have a different preference from their family caregivers. Regarding CPR, younger patients and patients from severely dysfunctional families were more likely to have a different preference from their family caregivers. Elucidation of the factors associated with such disparities should help reduce them.

Short-term and long-term mortality in very elderly patients admitted to an intensive care unit

OBJECTIVE

To report short-term and long-term mortality of very elderly ICU patients and to determine independent risk factors for short-term and long-term mortality

DESIGN AND SETTING

Retrospective cohort study in the medical/surgical ICU of a tertiary university teaching hospital.

PATIENTS

578 consecutive ICU patients aged 80 years or older.

RESULTS

Demographic, physiological, and laboratory values derived from the first 24h after ICU admission. ICU mortality of unplanned surgical (34.0%) and medical patients (37.7%) was higher than that of planned surgical patients (10.6%), as was post-ICU hospital mortality (26.5% and 29.7% vs. 4.4%). Mortality 12 months after hospital discharge, including ICU and hospital mortality, was 62.1% in unplanned surgical and 69.2% in medical patients vs. 21.6% in planned patients. Only median survival of planned surgical patients did not differ from survival in the age- and gender-matched general population. Independent risk factors for ICU mortality were lower Glasgow Coma Scale score, higher SAPS II score, the lowest urine output over 8 h, abnormal body temperature, low plasma bicarbonate levels, and higher oxygen fraction of inspired air. High urea concentrations and admission type were risk factors for hospital mortality, and high creatinine concentration was an independent risk factor for 12-month mortality.

CONCLUSION

Mortality in very elderly patients after unplanned surgical or medical ICU admission is higher than after planned admission. The most important factors independently associated with ICU mortality were related to the severity of illness at admission. Long-term mortality was associated with renal function.

Ethical, political, and social aspects of high-technology medicine: Eos and Care

OBJECTIVE

We discuss biosocial aspects of high-technology medicine (HTM) to provide a global view of the current model of medicine in the developed world and its consequences.

METHODS

We analyze changes in the concept of death and in the use and cost of HTM. The consequences of HTM on the delivery of basic medical care within and among countries are discussed. Concepts derived from Greek mythology are used to illustrate the problems associated with HTM.

RESULTS

HTM can be extremely effective in individual cases, but it poses important bioethical and biosocial problems. A major problem is related to the possibility of manipulating the process of dying and the consequent alteration in the social concept of death, which, if not carefully regulated, risks transforming medicine into an expensive way of pursuing pointless dreams of immortality (myth of Eos). Another problem is related to the extraordinary amount of resources necessary for HTM. This model of medicine (which is practiced daily) has limited sustainability, can work only in highly developed countries, may contribute to unequal access to health care, and has negligible positive impact on global health and survival.

CONCLUSIONS

HTM poses very important biosocial questions that need to be addressed in a wider and transparent debate, in the best interest of society and HTM as well.

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.

Mortality predictions in the intensive care unit: comparing physicians with scoring systems

OBJECTIVE

Risk-prediction models offer potential advantages over physician predictions of outcomes in the intensive care unit (ICU). Our systematic review compared the accuracy of ICU physicians' and scoring system predictions of ICU or hospital mortality of critically ill adults.

DATA SOURCE

MEDLINE (1966-2005), CINAHL (1982-2005), Ovid Healthstar (1975-2004), EMBASE (1980-2005), SciSearch (1980-2005), PsychLit (1985-2004), the Cochrane Library (Issue 1, 2005), PubMed "related articles," personal files, abstract proceedings, and reference lists.

STUDY SELECTION

We considered all studies that compared physician predictions of ICU or hospital survival of critically ill adults to an objective scoring system, computer model, or prediction rule. We excluded studies if they focused exclusively on the development or economic evaluation of a scoring system, computer model, or prediction rule.

DATA EXTRACTION AND ANALYSIS

We independently abstracted data and assessed study quality in duplicate. We determined summary receiver operating characteristic curves and areas under the summary receiver operating characteristic curves+/-se and summary diagnostic odds ratios.

DATA SYNTHESIS

We included 12 observational studies of moderate methodological quality. The area under the summary receiver operating characteristic curves for seven studies was 0.85+/-0.03 for physician predictions compared with 0.63+/-0.06 for scoring system predictions (p=.002). Physicians' summary diagnostic odds ratios derived from the area under the summary receiver operating characteristic curves were significantly higher (12.43; 95% confidence interval 5.47, 27.11) than scoring systems' summary diagnostic odds ratios (2.25; 95% confidence interval 0.78, 6.52, p=.001). Combined results of all 12 studies indicated that physicians predict mortality more accurately than do scoring systems: ratio of diagnostic odds ratios (95% confidence interval) 1.92 (1.19, 3.08) (p=.007).

CONCLUSIONS

Observational studies suggest that ICU physicians discriminate between survivors and nonsurvivors more accurately than do scoring systems in the first 24 hrs of ICU admission. The overall accuracy of both predictions of patient mortality was moderate, implying limited usefulness of outcome prediction in the first 24 hrs for clinical decision making.

Decision tools for life support: a review and policy analysis

OBJECTIVE

To identify, describe, and compare published documents intended to guide decisions about the administration, withholding, or withdrawal of life support in critical care.

DESIGN

Review article. SETTING AND SOURCES: Publicly available, English-language guidelines or decision tools for life support, identified through systematic literature search.

MEASUREMENTS AND MAIN RESULTS

Forty-nine documents were included and coded for authorship, source, development methodology, format, and positions taken on 12 common life-support issues. Sources were independent academics (n=21, 43%), professional organizations (n=19, 44%), and provider organizations. Eighteen documents (37%) described no development method. Twenty-three (47%) were produced collectively (e.g., by committees or consensus conference), 7 (14%) mentioned a literature review, and 2 (4%) were based upon the author's professional experience. Tools differed in format and focus; we characterize three types as decision schemas (involving clinical practice algorithms; n=7, 14%), decision guides (reviewing legal or professional positions; n=29, 59%), and decision counsels (more discursive and focusing typically on ethical issues; n=13, 27%). Tools addressed 12 common life-support issues: advance directives (67%), resource considerations (51%), ICU discharge criteria (27%), ICU admission criteria (16%), whether withholding differs from withdrawing life support (59%), whether nutrition and hydration decisions are different from decisions about other types of life support (61%), euthanasia (49%), double effect (47%), brain death (35%), special considerations for patients in a persistent vegetative state (51%), potential organ donors (12%), and pregnant patients (10%). Positions on these key life-support issues varied.

CONCLUSIONS

Published tools for guiding life-support decisions vary widely in their genesis, authorship, format, focus, and practicality. They also differ in their attention to, and positions on, key life-support dilemmas. Future research on decision tools should focus on how users interpret and apply the messages in these tools and their impacts on practice, quality of care, participant experiences, and outcomes.

Are terminally ill patients dying in the ICU suitable for non-heart beating organ donation?

OBJECTIVE

To evaluate the feasibility of implementing a program of controlled non-heart beating organ donation, in patients undergoing the withdrawal of intensive care treatment.

DESIGN AND SETTING

Prospective observational study. Medical and Surgical ICUs in a tertiary university hospital.

PATIENTS

Consecutive patients younger than 70 years dying in the ICU after treatment withdrawal for dire neurological prognosis.

MEASUREMENTS AND RESULTS

We analyzed prospectively collected data from the ICU clinical information system. Seventy-three of 516 ICU deaths (13%) were identified, equally distributed among traumatic, stroke, and anoxic brain injury. The management and the course in these three diagnostic categories were similar. All patients underwent withdrawal of mechanical ventilation and half were extubated. Median time to death was of 4.8 h (IQR 1.4-11.5). In 70% of cases the patient received analgesia and 30% sedation. Such treatment was not related to earlier death. Hypotension was observed in 50% of patients during the 30 min preceding cardiac death.

CONCLUSIONS

With our current management of terminal patients controlled non-heart beating organ procedure may be difficult due to the duration and variability of the dying process. This observation suggests that we can perform better by evaluating this process more closely.

Organ donations and unused potential donations in traumatic brain injury, subarachnoid haemorrhage and intracerebral haemorrhage

OBJECTIVE

To obtain insight into the occurrence of brain death and the potential for brain dead and controlled non-heart-beating organ donors (CNHB) in patients with traumatic brain injury (TBI), subarachnoid haemorrhage (SAH) and intracerebral haemorrhage (ICH) in a large neurosurgical serving area (2.1 million inhabitants).

DESIGN

Retrospective analysis of data concerning patients with TBI, SAH and ICH who died during the course of ICU treatment during 1999-2003.

SETTING

A 16-bed neuro-intensive care unit.

PATIENTS

Patients with TBI, SAH or ICH who died during the course of ICU treatment.

MEASUREMENTS AND RESULTS

The number of ICU deaths in patients with TBI, SAH and ICH declined from 111 in 1999 to 64 in 2003. In total, 476 deaths occurred. Of these, 177 patients were not included in the analysis. Two hundred ninety-nine (299) ventilated patients had two or more absent brainstem reflexes (ABSR) and a Glasgow Coma Score of 3-4 at the moment of treatment withdrawal and formed the potential for organ donation; 61 of these patients were treated until full brain death. Organs of 57 patients could be harvested. We analysed the reasons that organs were not procured in the 242 remaining patients. The most important reasons were family refusal (32%), medical contraindications (14%), and the treating physician not considering potential organ donation (20%). The missed potential is 162/299 (54%).

CONCLUSIONS

The number of actual and potential organ donors is declining, but a considerable number of potential CNHB donors exists. Refusal by relatives is the most important reason for failure to procure organs.