Paulo Maia

Communication of end-of-life decisions in European intensive care units.

ObjectiveTo 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.DesignData 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.Setting37 European ICUs in 17 countriesPatientsICU physicians collected data on 4,248 patients.Results95% 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%).ConclusionsICU 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

Nurse involvement in end-of-life decision making: the ETHICUS Study

ObjectiveThe purpose was to investigate physicians’ perceptions of the role of European intensive care nurses in end-of-life decision making.DesignThis study was part of a larger study sponsored by the Ethics Section of the European Society of Intensive Care Medicine, the ETHICUS Study. Physicians described whether they thought nurses were involved in such decisions, whether nurses initiated such a discussion and whether there was agreement between physicians and nurses. The items were analyzed and comparisons were made between different regions within Europe.SettingThe study took place in 37 intensive care units in 17 European countries.Patients and participantsPhysician investigators reported data related to patients from 37 centers in 17 European countries.InterventionsNone.Measurements and resultsPhysicians perceived nurses as involved in 2,412 (78.3%) of the 3,086 end-of-life decisions (EOLD) made. Nurses were thought to initiate the discussion in 66 cases (2.1%), while ICU physicians were cited in 2,438 cases (79.3%), the primary physician in 328 cases (10.7%), the consulting physician in 105 cases (3.4%), the family in 119 cases (3.9%) and the patient in 19 cases (0.6%). In only 20 responses (0.6%) did physicians report disagreement between physicians and nurses related to EOLD. A significant association was found between the region and responses to the items related to nursing. Physicians in more northern regions reported more nurse involvement.ConclusionsPhysicians perceive nurses as involved to a large extent in EOLDs, but not as initiating the discussion. Once a decision is made, there is a sense of agreement. The level of perceived participation is different for different regions.

Relieving suffering or intentionally hastening death: where do you draw the line?

Objective:End-of-life practices vary worldwide. The objective was to demonstrate that there is no clear-cut distinction between treatments administered to relieve pain and suffering and those intended to shorten the dying process. Design:Secondary analysis of a prospective, observational study. Setting:Thirty-seven intensive care units in 17 European countries. Patients:Consecutive patients dying or with any limitation of therapy. Interventions:Evaluation of the type of end-of-life category; dates and times of intensive care unit admission, death, or discharge; and decisions to limit therapy, medication, and doses used for active shortening of the dying process and the intent of the doctors prescribing the medication. Measurements and Main Results:Limitation of life-sustaining therapy occurred in 3,086 (72.6%) of 4,248 patients, and 94 (2.2%) underwent active shortening of the dying process. Medication for active shortening of the dying process included administration of opiates (morphine to 71 patients) or benzodiazepines (diazepam to 54 patients) alone or in combination. The median dosage for morphine was 25.0 mg/hr and for diazepam 20.8 mg/hr. Doses of opiates and benzodiazepines were no higher than mean doses used with withdrawal in previous studies in 20 of 66 patients and were within the ranges of doses used in all but one patient. Doctors considered that medications for active shortening of the dying process definitely led to the patients death in 72 patients (77%), probably led to the patients death in 11 (12%), and were unlikely to have led to death in 11 (12%) patients. Conclusions:There is a gray area in end-of-life care between treatments administered to relieve pain and suffering and those intended to shorten the dying process.

Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The Ethicatt study

PurposeThis study explored differences in end-of-life (EOL) decisions and respect for patient autonomy of religious members versus those only affiliated to that particular religion (affiliated is a member without strong religious feelings).MethodsIn 2005 structured questionnaires regarding EOL decisions were distributed in six European countries to ICUs in 142 hospital ICUs. This sub-study of the original data analyzed answers from Protestants, Catholics and Jews.ResultsA total of 304 physicians, 386 nurses, 248 patients and 330 family members were included in the study. Professionals wanted less treatment (ICU admission, CPR, ventilator treatment) than patients and family members. Religious respondents wanted more treatment and were more in favor of life prolongation, and they were less likely to want active euthanasia than those affiliated. Southern nurses and doctors favored euthanasia more than their Northern colleagues. Three quarters of doctors and nurses would respect a competent patient’s refusal of a potentially life-saving treatment. No differences were found between religious and affiliated professionals regarding patient’s autonomy. Inter-religious differences were detected, with Protestants most likely to follow competent patients’ wishes and the Jewish respondents least likely to do so, and Jewish professionals more frequently accepting patients’ wishes for futile treatment. However, these findings on autonomy were due to regional differences, not religious ones.ConclusionsHealth-care professionals, families and patients who are religious will frequently want more extensive treatment than affiliated individuals. Views on active euthanasia are influenced by both religion and region, whereas views on patient autonomy are apparently more influenced by region.

Inappropriate Care in European ICUs: Confronting Views From Nurses and Junior and Senior Physicians

BACKGROUND ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power. METHODS We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations. RESULTS By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups. CONCLUSIONS ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.

Original ResearchCritical CareInappropriate Care in European ICUs: Confronting Views From Nurses and Junior and Senior Physicians

BACKGROUND ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power. METHODS We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations. RESULTS By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups. CONCLUSIONS ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.

Attitudes of European physicians, nurses, patients and families regarding end-of-life decisions: the ETHICATT study. Reply to A.M. Vrakking

Sweden Terminal illness 120 32 257 68 Permanent unconsciousness 135 36 241 64 England Terminal illness 85 34 165 66 Permanent unconsciousness 104 42 144 58 Holland Terminal illness 137 43 179 57 Permanent unconsciousness 202 65 107 35 Czech Republic Terminal illness 113 53 101 47 Permanent unconsciousness 98 47 112 53 Portugal Terminal illness 153 50 153 50 Permanent unconsciousness 129 43 172 57 Israel Terminal illness 167 46 194 54 Permanent unconsciousness 175 49 181 51 Total Terminal illness 775 43 1049 58 Permanent unconsciousness 843 47 957 53