End-of-life care in Spain: legal framework

Abstract

Prominent cases affecting care at the end of life in critically ill patients have been reported in several European countries [1, 2]. These cases have fueled a necessary debate regarding the need of having a legal framework to appropriately deal with these issues [3, 4]. In Spain, there is no specific legislation regulating the withdrawal or withholding of treatment in end-of-life care or in critical patients on life support. However, the avoidance of inappropriate prolongation of life and the withdrawal or withholding of life support when the patient desires it or when it is considered futile is considered good clinical practice [5]. This decision takes place in the confidential context of the physician–patient relationship. A few months ago, a patient who was permanently a ventilator dependent because of a progressive muscle dystrophia, asked for ventilator withdrawal. This patient, who had always complete consciousness to take decisions, was admitted in a hospital owned by the church. The ecclesiastic hierarchy dealt with her petition and decided to transfer the patient to a public hospital, where ventilator support was withdrawn by her responsible physician. Such process is not considered euthanasia but withdrawal of life support. The case was widely commented on the press, but no judiciary process was carried out [6]. The Spanish Society of Intensive and Critical Care and Coronary Units (SEMICYUC) has published guidelines about end-of-life decisions [7]. A recent multicenter study showed that 71% of patients, who died in the ICU because of a multiple organ dysfunction syndrome, had some type of limitation of treatment [8]. Furthermore, the vast majority (over 95%) of critical care departments in Spain is made up of intensivists that have completed the Department of Health’s MIR (medicos internos y residentes) specialist training in intensive medicine and therefore these departments have also adopted the SEMICYUC’s guidelines. In Spain there are publications [9, 10] dealing with different aspects of therapeutic decisions in end-of-life care in the critically ill patients which are covered by diverse authors, including physicians, jurists, philosophers and nurses.