Abstract
IntroductionEnd-of-life-decisions (EOLD) have become an important part of modern intensive care medicine. With increasing therapeutic possibilities on the one hand and many ICU-patients lacking decision making capacity or an advance directive on the other the decision making process is a major challenge on the intensive care unit (ICU). Currently, data are poor on factors associated with EOLD in Germany. In 2009, a new law on advance directives binding physicians and the patient´s surrogate decision makers was enacted in Germany. So far it is unknown if this law influenced proceedings of EOLD making on the ICU.MethodsA retrospective analysis was conducted on all deceased patients (n = 224) in a 22-bed surgical ICU of a German university medical center from 08/2008 to 09/2010. Patient characteristics were compared between patients with an EOLD and those without an EOLD. Patients with an EOLD admitted before and after change of legislation were compared with respect to frequencies of EOLD performance as well as advance directive rates.ResultsIn total, 166 (74.1%) of deaths occurred after an EOLD. Compared to patients without an EOLD, comorbidities, ICU severity scores, and organ replacement technology did not differ significantly. EOLDs were shared within the caregiverteam and with the patient´s surrogate decision makers. After law enacting, no differences in EOLD performance or frequency of advance directives (8.9% vs. 9.9%; p = 0.807) were observed except an increase of documentation efforts associated with EOLDs (18.7% vs. 43.6%; p<0.001).ConclusionsIn our ICU EOLD proceedings were performed patient-individually. But EOLDs follow a standard of shared decision making within the caregiverteam and the patient´s surrogate decision makers. Enacting a law on advance directives has not affected the decision making-process in EOLDs nor has it affected population´s advance care planning habits. However, it has led to increased EOLD-associated documentation on the ICU.Trail RegistrationClinicalTrials.gov NCT01294189.
Highlights
End-of-life-decisions (EOLD) have become an important part of modern intensive care medicine
EOLDs follow a standard of shared decision making within the caregiverteam and the patients surrogate decision makers
EOLDs were taken within a median intensive care unit (ICU) length of stay (LOS) of five days for DNRs (interquartile range (IQR): 2–15) as well as for withhold and/or withdraw life support (WH/WDLS) decisions (IQR: 2–19)
Summary
End-of-life-decisions (EOLD) have become an important part of modern intensive care medicine. In 2009, a new law on advance directives binding physicians and the patients surrogate decision makers was enacted in Germany. It is unknown if this law influenced proceedings of EOLD making on the ICU. Most patients in the intensive care unit (ICU) (60%–80%) die after an end-of-life-decision (EOLD) has been made, a decision to limit full life support [1,2,3,4,7,8]. In Europe and the US the majority of people favours this concept [9,10,11,12,13] This model becomes complicated when a patient loses decision making capacity. A patientss attorney or surrogate decision maker is not allowed to overrule a patients advance directive as it was possible priorly [17]
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