Abstract
Background and Objectives: Mortality on Intensive Care Units (ICUs) is high and death frequently occurs after decisions to limit life-sustaining therapies. An advance directive is a tool meant to preserve patient autonomy by guiding anticipated future treatment decisions once decision-making capacity is lost. Since September 2009, advance directives are legally binding for the caregiver team and the patients’ surrogate decision-maker in Germany. The change in frequencies of end-of-life decisions (EOLDs) and completed advance directives among deceased ICU patients ten years after the enactment of a law on advance directives in Germany is unknown. Materials and Methods: Retrospective analysis on all deceased patients of surgical ICUs of a German university medical center from 08/2008 to 09/2009 and from 01/2019 to 09/2019. Frequency of EOLDs and advance directives and the process of EOLDs were compared between patients admitted before and after the change in legislation. (No. of ethical approval EA2/308/20) Results: Significantly more EOLDs occurred in the 2019 cohort compared to the 2009 cohort (85.8% vs. 70.7% of deceased patients, p = 0.006). The number of patients possessing an advance directive to express a living or therapeutic will was higher in the 2019 cohort compared to the 2009 cohort (26.4% vs. 8.9%; difference: 17.5%, p < 0.001). Participation of the patients’ family in the EOLD process (74.7% vs. 60.9%; difference: 13.8%, p = 0.048) and the frequency of documentation of EOLD-relevant information (50.0% vs. 18.7%; difference: 31.3%, p < 0.001) increased from 2009 to 2019. Discussion: During a ten-year period from 2009 to 2019, the frequency of EOLDs and the completion rate of advance directives have increased considerably. In addition, EOLD-associated communication and documentation have further improved.
Highlights
Organ support and replacement technology on the Intensive Care Unit (ICU) has converted death from a sudden and often unexpected event to a process which is dependent of the level of provision of care and organ support [1]
Frequency of end-oflife decisions (EOLDs) and advance directives and the process of EOLDs were compared between patients admitted before and after the change in legislation. (No of ethical approval EA2/308/20) Results: Significantly more EOLDs occurred in the 2019 cohort compared to the 2009 cohort (85.8% vs. 70.7% of deceased patients, p = 0.006)
Compared with patients included in the 2009 cohort, patients in the 2019 cohort did not differ in median age, sex, urgency of admission, disease severity measured by ICU severity scores APACHE II and SAPS2, and in ICU-length of stay (LOS) (Table 1)
Summary
Organ support and replacement technology on the Intensive Care Unit (ICU) has converted death from a sudden and often unexpected event to a process which is dependent of the level of provision of care and organ support [1]. Patients often die after individual decisions to limit life-sustaining ICU therapy have been made [2,3]. EOLDs are based on the principle of shared decision-making between the caregiver team and the patient or his surrogate decision maker [4]. They show a regional variety due to their association with culture, religion, and different laws and healthcare systems [3]. With a written advance directive, patients can document their personal will, values, and preferences, including the definition of a personal surrogate decision maker in advance of an anticipated situation when decision-making capacity is lost. EOLD-associated communication and documentation have further improved
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