End-of-life decisions in Greek intensive care units: a multicenter cohort study

Georgios Kranidiotis 0 Vasiliki Gerovasili 0 Athanasios Tasoulis 2 Elli Tripodaki 0 Ioannis Vasileiadis 1 Eleni Magira 6 Vasiliki Markaki 0 Christina Routsi 0 Athanasios Prekates 6 Theodoros Kyprianou 5 Phyllis-Maria Clouva-Molyvdas 1 Georgios Georgiadis 4 Ioannis Floros 3 Andreas Karabinis 7 Serafim Nanas 0 0 First Critical Care Department, Evangelismos Hospital, National and Kapodistrian University of Athens , 45-47 Ypsilantou Str, Athens, 10675 , Greece 1 Critical Care Department, Thriassio General Hospital , G. Gennimata Av, Eleusis, 19600 , Greece 2 Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens , 80 Vasilissis Sofias Av, Athens, 11528 , Greece 3 Critical Care Department, Laiko General Hospital , 17 Aghiou Thoma Str., Athens, 11527 , Greece 4 Critical Care Department, Metropolitan Hospital , Ethnarhou Makariou & 1 Eleutheriou Venizelou Str., Athens, 18547 , Greece 5 Critical Care Department, Nicosia General Hospital , 215 Old Road Nikosia-Limassol, Nikosia, 2029 , Cyprus 6 Critical Care Department, Tzaneio General Hospital , Afentouli & Zanni Str., Piraeus, 18536 , Greece 7 Critical Care Department, G. Gennimatas General Hospital , 154 Mesogeion Av, Athens, 11527 , Greece 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. - Introduction Intensive care may prolong the dying process in patients who have been unresponsive to the treatment already provided and for whom the possibility of surviving or regaining an acceptable quality of life is nil. Withholding and withdrawal of life-sustaining treatment were introduced to avoid the futile suffering of dying patients. These practices are based on the principles of bioethics; they are common worldwide, have been approved by the international scientific community, and must not be confused with euthanasia [1,2]. Observational studies conducted in several countries on different continents showed that a large proportion of intensive care unit (ICU) deaths are preceded by withholding or withdrawal of treatment, and that a variety of clinical parameters are associated with the decision to limit treatment [3-12]. The frequency of withholding or withdrawal of treatment and the degree of involvement of relatives in the decision making are influenced by the cultural context [13,14]. The objective of this multicenter study was to study the frequency, types, and rationale for limiting life support in Greek multidisciplinary ICUs, the clinical and demographic parameters associated with it, and the participation of relatives in the decision-making process. Materials and methods This was a prospective observational study conducted in eight multidisciplinary, general hospital-affiliated ICUs (seven in Athens, and one in Nicosia, Cyprus). The contribution of each ICU and the dates defining the periods of data collection are presented in Table 1. In terms of the number of beds, the participating ICUs represent about one third of the total in Greece and Cyprus. We studied all consecutive ICU patients who died, excluding those who stayed in the ICU less than 48 hours or were diagnosed with brain death. The physician in charge of each study patient was invited 1. To classify the patient into one of four mutually exclusive categories: patients who received full support, including unsuccessful cardiopulmonary resuscitation (CPR) (group A); those who received active support up to but not including CPR (group B); those with a decision to withhold (not to start/escalate) some form of life support besides CPR (group C); or those with a decision to withdraw an existing form of life support (group D). 2. To complete an anonymous questionnaire, indicat ing the factors that influenced his or her decision to offer full support or to limit therapy (choosing them from among a list of prespecified items and weighing them on a scale ranging from 0 for no impact to 4 for ultimate impact), the degree and nature of relatives involvement in the decision-making process, the reasons for not discussing end-of-life dilemmas with the patient and family, whether a consensus was reached in the medical team about the decision, and whether advance directives existed. In addition, if a decision to limit therapy was taken, the physician was asked to note the life-support modalities withheld or withdrawn. The physicians of each ICU deposited the completed questionnaire in a sealed unmarked box. The several boxes collected from participating ICUs were mixed and opened all together at the end of the study. For all patients, the following clin (...truncated)