Objective
To evaluate physicians' reasoning, considerations and possible difficulties in end-of-life decision-making for patients in European intensive care units (ICUs).
Design
A prospective ...observational study.
Setting
Thirty-seven ICUs in 17 European countries.
Patients and participants
A total of 3,086 patients for whom an end-of-life decision was taken between January 1999 and June 2000. The dataset excludes patients who died after attempts at cardiopulmonary resuscitation and brain-dead patients.
Measurements and results
Physicians indicated which of a pre-determined set of reasons for, considerations in, and difficulties with end-of-life decision-making was germane in each case as it arose. Overall, 2,134 (69%) of the decisions were documented in the medical record, with inter-regional differences in documentation practice. Primary reasons given by physicians for the decision mostly concerned the patient's medical condition (79%), especially unresponsive to therapy (46%), while chronic disease (12%), quality of life (4%), age (2%) and patient or family request (2%) were infrequent. Good medical practice (66%) and best interests (29%) were the commonest primary considerations reported, while resource allocation issues such as cost effectiveness (1%) and need for an ICU bed (0%) were uncommon. Living wills were considered in only 1% of cases. Physicians in central Europe reported no significant difficulty in 81% of cases, while in northern and southern regions there was no difficulty in 92–93% of cases.
Conclusions
European ICU physicians do not experience difficulties with end-of-life decisions in most cases. Allocation of limited resources is a minor consideration and autonomous choices by patient or family remain unusual. Inter-regional differences were found.
To examine end-of-life (EOL) practices in European ICUs: who makes these decisions, how they are made, communication of these decisions and questions on communication between the physicians, nurses, ...patients and families.
Data collected prospectively on EOL decisions facilitated by a questionnaire including EOL decision categories, geographical regions, mental competency, information about patient wishes, and discussions with patients, families and health care professionals.
37 European ICUs in 17 countries.
ICU physicians collected data on 4,248 patients.
95% of patients lacked decision making capacity at the time of EOL decision and patient's wishes were known in only 20% of cases. EOL decisions were discussed with the family in 68% of cases. Physicians reported having more information about patients' wishes and discussions in the northern countries (31%, 88%) than central (16%, 70%) or southern (13%, 48%) countries. The family was more often told (88%) than asked (38%) about EOL decisions. Physicians' reasons for not discussing EOL care with the family included the fact that the patient was unresponsive to therapy (39%), the family was unavailable (28%), and the family was thought not to understand (25%).
ICU patients typically lack decision-making capacity, and physicians know patients' wishes in only 20% of EOL decisions. There were regional differences in discussions of EOL decisions with families and other physicians. In European ICUs there seems to be a need to improve communication.
Background and objective: the sociotype and its domains - Individual Health (IH), Relationships (R) and Context (C) - extends the bio-psychosocial model as an ecological construct that interacts with ...the genotype to determine phenotypic behavior throughout life. The sociotype framework enables classifying both the nature of stress and the varying responses to it. This paper provides empirical evidence for the sociotype and examines its relation to perceived coping.
Design and methods: we conducted a secondary analysis of a cross-sectional survey on health inequalities in a representative Israeli Jewish sample of 1328 individuals, 30-70 yrs (45% men). Thirty variables were arranged into the above domains and composite scores calculated from sequential regression analyses. A coping score (CS) was determined from questions relating to mastery and coping efficacy.
Results: The mean population CS was 5.09 (SD 1.03; range 1.50-7.20); 5.23 for men vs. 4.97 for women (p < .00001). On univariate analysis, CS was not related to age; there were positive associations with health behaviors, education and economic situation and negative ones with smoking, stress and living alone. Correlations between the three domains ranged from 0.353 to 0.421 (all at p < .001). The individual contributions of each of the sociotype domains to the CS was 31.5% for IH, 16.8% for R and 17.8% for C; when combined they explained 32% of the variance. This was higher in men (40.7%) than in women (26.0%), who valued context more than relationships.
Conclusions: In this population, the domains of the sociotype were related to perceived coping: longitudinal studies can determine its best predictors and the significance of any gender differences. The sociotype ecological model requires further testing in different settings, and for other phenotypic behaviors and responses to stresses, such as coping with chronic disease (adherence to medication) (IH), bereavement (R) and economic hardships (C).
Cranial ischemic complications (CICs) are among the presenting manifestations of giant cell arteritis (GCA). Yet patients with GCA may develop CICs at a later stage, despite steroid therapy. In the ...current report we delineate risk factors for CICs, both at presentation and during follow-up, and review the relevant literature. We reviewed charts of 175 patients with GCA. Follow-up data were available for 166 patients. CICs at presentation or developing within 2 weeks of GCA diagnosis were considered GCA related. CICs developing later were considered GCA related only when associated with other GCA-related manifestations or acute-phase reactions. Associations between CICs and other variables were tested by multivariate analysis. At presentation, 43 patients (24.6%) had CICs. Risk factors were transient cerebro-ophthalmic ischemic episodes (COIEs) (odds ratio OR 4.3) and male sex (OR 2.5), while the presence of systemic symptoms was "protective" (OR 0.3). During follow-up 8.4% of patients with GCA developed new CICs. Risk factors in these cases were previous CICs at presentation (OR 5.6) and transient COIEs developing during follow-up (OR 14.8). The use of low-dose aspirin was protective (OR 0.2). These data, together with data from the literature review, suggest that GCA patients with transient COIEs and without fever or other systemic symptoms are at increased risk of presenting with CICs. Risk factors for late-developing CICs were CICs at presentation and late-developing transient COIEs.
To assess the report of low back pain (LBP) over 1 year and its predictors in individuals reporting symptoms during an initial cross-sectional survey.
A longitudinal community-based study.
The ...natural history of LBP is poorly understood. Different studies report various rates of persistent and recurrent symptoms as well as different predictors of outcomes.
Subjects from a single town in Israel reporting low back pain during the previous month were followed up after 2 and 12 months. The primary outcome was experiencing LBP and the secondary outcomes were pain and functional status as measured by the Roland & Morris Disability questionnaire and Pain Symptoms Frequency and Bothersomeness Indexes.
More than three fourths reported LBP (different levels of severity) after 2 and 12 months. This group did not show an improvement in pain measures. Baseline pain characteristics and perception of general health were predictors of both primary and secondary outcomes. Work satisfaction and experiencing a negative event during the past months were also predictors of the secondary outcomes.
In this community-based study, LBP symptoms after 1 year are common and symptoms of those experiencing LBP at follow up do not improve over time. Predictors of experiencing LBP and of LBP symptoms after 1 year included baseline pain characteristics and psychosocial factors.
Great differences in end-of-life practices in treating the critically ill around the world warrant agreement regarding the major ethical principles. This analysis determines the extent of worldwide ...consensus for end-of-life practices, delineates where there is and is not consensus, and analyzes reasons for lack of consensus. Critical care societies worldwide were invited to participate. Country coordinators were identified and draft statements were developed for major end-of-life issues and translated into six languages. Multidisciplinary responses using a web-based survey assessed agreement or disagreement with definitions and statements linked to anonymous demographic information. Consensus was prospectively defined as >80% agreement. Definitions and statements not obtaining consensus were revised based on comments of respondents, and then translated and redistributed. Of the initial 1,283 responses from 32 countries, consensus was found for 66 (81%) of the 81 definitions and statements; 26 (32%) had >90% agreement. With 83 additional responses to the original questionnaire (1,366 total) and 604 responses to the revised statements, consensus could be obtained for another 11 of the 15 statements. Consensus was obtained for informed consent, withholding and withdrawing life-sustaining treatment, legal requirements, intensive care unit therapies, cardiopulmonary resuscitation, shared decision making, medical and nursing consensus, brain death, and palliative care. Consensus was obtained for 77 of 81 (95%) statements. Worldwide consensus could be developed for the majority of definitions and statements about end-of-life practices. Statements achieving consensus provide standards of practice for end-of-life care; statements without consensus identify important areas for future research.
To develop an enhanced understanding of factors that influence providers' views about end-of-life care, we examined the contributions of provider, hospital, and country to variability in agreement ...with consensus statements about end-of-life care.
Data were drawn from a survey of providers' views on principles of end-of-life care obtained during the consensus process for the Worldwide End-of-Life Practice for Patients in ICUs study.
Participants in Worldwide End-of-Life Practice for Patients in ICUs included physicians, nurses, and other providers. Our sample included 1,068 providers from 178 hospitals and 31 countries.
None.
We examined views on cardiopulmonary resuscitation and withholding/withdrawing life-sustaining treatments, using a three-level linear mixed model of responses from providers within hospitals within countries. Of 1,068 providers from 178 hospitals and 31 countries, 1% strongly disagreed, 7% disagreed, 11% were neutral, 44% agreed, and 36% strongly agreed with declining to offer cardiopulmonary resuscitation when not indicated. Of the total variability in those responses, 98%, 0%, and 2% were explained by differences among providers, hospitals, and countries, respectively. After accounting for provider characteristics and hospital size, the variance partition was similar. Results were similar for withholding/withdrawing life-sustaining treatments.
Variability in agreement with consensus statements about end-of-life care is related primarily to differences among providers. Acknowledging the primary source of variability may facilitate efforts to achieve consensus and improve decision-making for critically ill patients and their family members at the end of life.
Life and death triage decisions are made daily by intensive care unit physicians. Admission to an intensive care unit is denied when intensive care unit resources are constrained, especially for the ...elderly.
To determine the effect of intensive care unit triage decisions on mortality and intensive care unit benefit, specifically for elderly patients.
Prospective, observational study of triage decisions from September 2003 until March 2005.
Eleven intensive care units in seven European countries.
All patients >18 yrs with an explicit request for intensive care unit admission.
Admission or rejection to intensive care unit.
Demographic, clinical, hospital, physiologic variables, and 28-day mortality were obtained on consecutive patients. There were 8,472 triages in 6,796 patients, 5,602 (82%) were accepted to the intensive care unit, 1,194 (18%) rejected; 3,795 (49%) were ≥ 65 yrs. Refusal rate increased with increasing patient age (18-44: 11%; 45-64: 15%; 65-74: 18%; 75-84: 23%; >84: 36%). Mortality was higher for older patients (18-44: 11%; 45-64: 21%; 65-74: 29%; 75-84: 37%; >84: 48%). Differences between mortalities of accepted vs. rejected patients, however, were greatest for older patients (18-44: 10.2% vs. 12.5%; 45-64: 21.2% vs. 22.3%; 65-74: 27.9% vs. 34.6%; 75-84: 35.5% vs. 40.4%; >84: 41.5% vs. 58.5%). Logistic regression showed a greater mortality reduction for accepted vs. rejected patients corrected for disease severity for elderly patients (age >65 odds ratio 0.65, 95% confidence interval 0.55-0.78, p < .0001) than younger patients (age <65 odds ratio 0.74, 95% confidence interval 0.57-0.97, p = .01).
Despite the fact that elderly patients have more intensive care unit rejections than younger patients and have a higher mortality when admitted, the mortality benefit appears greater for the elderly. Physicians should consider changing their intensive care unit triage practices for the elderly.
While the adoption of practice guidelines is standardizing many aspects of patient care, ethical dilemmas are occurring because of forgoing life-sustaining therapies in intensive care and are dealt ...with in diverse ways between different countries and cultures.
To determine the frequency and types of actual end-of-life practices in European intensive care units (ICUs) and to analyze the similarities and differences.
A prospective, observational study of European ICUs.
Consecutive patients who died or had any limitation of therapy.
Prospectively defined end-of-life practices in 37 ICUs in 17 European countries were studied from January 1, 1999, to June 30, 2000.
Comparison and analysis of the frequencies and patterns of end-of-life care by geographic regions and different patients and professionals.
Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%) had limitations of treatments (10% of admissions). Substantial intercountry variability was found in the limitations and the manner of dying: unsuccessful cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range, 0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range, 0%-19%). Shortening of the dying process was reported in 7 countries. Doses of opioids and benzodiazepines reported for shortening of the dying process were in the same range as those used for symptom relief in previous studies. Limitation of therapy vs continuation of life-sustaining therapy was associated with patient age, acute and chronic diagnoses, number of days in ICU, region, and religion (P<.001).
The limiting of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors. Although shortening of the dying process is rare, clarity between withdrawing therapies and shortening of the dying process and between therapies intended to relieve pain and suffering and those intended to shorten the dying process may be lacking.
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