Withholding Of Life-sustaining Treatment Research Articles

Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study

BackgroundClinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches.MethodsThis was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality.ResultsThere were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987–19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351–60.298) were both found to be independent predictors of hospital mortality on multivariable analysis.ConclusionsDifferences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.

Abstract WP157: Withdrawing and Withholding of Life Sustaining Treatment After Stroke: Understanding the Content of Discussion With Families &amp; Review of Symptoms at End of Life

Background: Stroke kills 160,000 patients every year in the US. Most patients who die with stroke do so in hospital. Little is known about the acute dying process or experience of patients with stroke and their families. Objectives: The goal of this quality improvement project is to better understand the end-of-life process in patients dying with stroke at our institution, focusing on patients who were awake at end of life. Methods: Of patients admitted to our academic medical center in 2022 with stroke who died, we collected basic characteristics and information about reasoning behind WLST and the patient’s condition immediately after WLST. Among those who showed signs of wakefulness (tracking examiner or better), we searched the chart for any documentation of broadly defined goals of care conversations and patient or family symptoms assessed at end of life. Results: Of 525 patients, 118 patients (22.5%) died in hospital. Basic characteristics are listed in Table 1. WLST occurred in 99 patients (84% of decedents), of whom 33 (27.8%) showed signs of wakefulness at time of WLST. None of the patients participated in conversations, and a documented advance directive was followed in 5 (15%). After WLST, patient symptoms most frequently documented by clinicians included dyspnea (n=29), pain (n=18), and restlessness (n=12), but no non-physical symptoms (see Table 2). Family symptoms were not documented. Discussion: At least one quarter of hospital decedents after stroke showed signs of wakefulness, with patient-centered symptoms rarely documented. A standardized, systematic symptom assessment is needed to truly understand signs and symptoms during end-of life for patients with stroke.

The Impact of Withdrawing or Withholding of Life-Sustaining Treatment: A Nationwide Case-Control Study Based on Medical Cost Analysis.

This study measured the impact of the Decisions on Life-Sustaining Treatment Act by analyzing medical cost data from the National Health Insurance Service-National Sample Cohort. After identifying the patients who died in 2018 and 2019, the case and control groups were set using the presence of codes for managing the implementation of life-sustaining treatment with propensity score matching. Regarding medical costs, the case group had higher medical costs for all periods before death. The subdivided items of medical costs with significant differences were as follows: consultation, admission, injection, laboratory tests, imaging and radiation therapy, nursing hospital bundled payment, and special equipment. This study is the first analysis carried out to measure the impact of the Decision on Life-Sustaining Treatment Act through a cost analysis and to refute the common expectation that patients who decided to withhold or withdraw life-sustaining treatment would go through fewer unnecessary tests or treatments.

The Characteristics of Withdrawal or Withholding of Life-Sustaining Treatment in Severe Traumatic Brain Injury: A Single Japanese Institutional Study

There is little evidence on the factors influencing the decision to withdraw or continue life-sustaining treatment in the setting of severe traumatic brain injury in Japanese institutions. We investigated the factors associated with the withdrawal or withholding of life-sustaining treatment (WLST) for severe traumatic brain injury at a single Japanese institution. A total of 161 patients with severe traumatic brain injury were retrospectively reviewed. Patient characteristics and injury types were compared between patients with and without the WLST. Of the 161 patients, 87 (54%) died and 52 (32%) decided to undergo WLST. In 98% of the WLST cases, the decision was made within 24h of admission. The mean duration between WLST and death was 2days. The predicted probabilities for mortality and unfavorable outcomes were highest in patients with WLST within 24h. Patients with WLST were older and had a higher frequency of falls on the ground, ischemic heart disease, and acute subdural hemorrhage than those without WLST. The decisions of almost all WLST cases were made within 24h of admission for severe traumatic brain injury in a Japanese institution because of Japanese patients' religious and cultural backgrounds.

Exploring physician approaches to conflict resolution in end-of-life decisions in the adult intensive care unit: protocol for a systematic review of qualitative research

IntroductionConflict is unfortunately well-documented in the adult intensive care unit (AICU). In the context of end-of-life (EOL) decision-making (ie, the withdrawal or withholding of life-sustaining treatment), conflict commonly occurs when...

Quebec population highly supportive of extending Medical Aid in Dying to incapacitated persons and people suffering only from a mental illness: Content analysis of attitudes and representations

In 2015, the province of Quebec in Canada became one of the few jurisdictions to legalize medically assisted dying. Thereafter, a public commission was mandated to study the extension of Medical Aid in Dying (MAiD) to incapacitated persons and people suffering from only a mental illness. To better understand debates concerning different forms of assisted dying and their eligibility conditions, we assessed the attitudes of the Quebec general population toward extending Medical Aid in Dying to incapacitated persons and those suffering only from a mental illness and their representations of those practices. We conducted an interpretative content analysis of 31 semi-structured interviews conducted as part of a large-scale study aimed at documenting Knowledge, Attitudes, and Representations of Quebecers regarding MAiD, continuous palliative sedation, and palliative care (KAR Study). Our analysis was complexified since participants often mixed responses regarding different current and proposed end-of-life practices, and they frequently declared a lack of knowledge of practices. To illustrate this emerging aspect of our results, we quantitated the content of the interview transcripts to create a structured qualitative dataset. Of the 31 participants, 29 were in favour of MAiD. All those in favour considered that the practice should be accessible to incapacitated persons and 27 of them believed that access should be granted to those who suffer only from a mental illness. However, 20 of the 31 participants (64.5%) confused the term Medical Aid in Dying with other legal forms of end-of-life practices such as palliative care, withdrawing, and withholding of life-sustaining treatments, and advance directives about treatment. Sixteen (51.6%) said they lacked knowledge about one or several of the end-of-life practices discussed in the interview. Although the participants were very favorable toward MAiD, there was widespread confusion in participants’ understanding of what constitutes MAiD, thinking it includes other currently legal end-of-life practices. It is not possible to determine whether our participants were in favour of the extension of MAiD to incapacitated persons and people suffering from mental illnesses, or if they were in favour of various currently legal end-of-life interventions for those populations.

Physician Approaches to Addressing Conflict Arising in End-of-Life Decision-Making in the Adult Intensive Care Unit: A Systematic Review

"Background: Conflict is unfortunately well-documented in the adult intensive care unit (AICU). In the context of end-of-life (EOL) decision-making (i.e. the withdrawal or withholding of life-sustaining treatment), conflict commonly occurs when a consensus cannot be reached between the healthcare team and the patient’s family on the “best interests” of the critically ill, incapacitated patient, as per England’s Mental Capacity Act 2005. Whilst existing literature has identified potential routes for conflict resolution, it is less clear how these approaches are perceived and utilised by stakeholders in the EOL decision-making process. Aim: We aim to explore this by systematically reviewing and synthesising the published evidence, which addresses the following research question: what does existing qualitative research reveal about physician approaches to addressing conflict arising in EOL decisions in the AICU? Methods: Peer-reviewed qualitative studies (retrieved from MEDLINE, Project Muse, EMBASE, Web of Science, PsycINFO, CINAHL and LILACS) examining conflict and dispute resolution in the context of EOL decisions in the AICU setting will be included. Two reviewers will independently screen for eligibility and extract data from either all or 10% of the included studies, with a third reviewer independently screening studies of uncertain eligibility. The ‘thematic synthesis’ approach will be utilised to analyse the resulting data (Thomas &amp; Harden, 2008). The systematic review is currently underway, laying the foundations for a larger empirical study, undertaken for a PhD, funded by the Wellcome Trust BABEL (Balancing Best Interests in Healthcare, Ethics, and Law) Collaborative Award. The results will be presented at the conference. "

End-of-life decision making in critical illness: Perspectives of Asian parents

To explore parents' perspectives regarding end-of-life (EOL) decisions, factors and possible barriers that influence the EOL decision making process, and to understand parental preferences for communication about EOL care in an Asian population. A prospective questionnaire cohort study conducted in a university-based tertiary care hospital. 30 parents of children who had been admitted to general pediatric wards for acute ailments and/or were being followed up in general pediatric outpatient clinics after inpatient admissions or emergency department visits completed 30 interviewer-administered questionnaires. With the first 10 completed questionnaires, we sought feedback on the design of the four case vignettes and related questions. Responses to specific questions related to each case vignette were rated on a Likert scale. The majority of parents were able to comprehend and identify with the issues in the case vignettes, which allowed them to respond appropriately. Parents tended to avoid active withdrawal or withholding of life-sustaining treatment. The top three priorities for parents making EOL decisions for their children were: the chance of improvement, the presence of pain or discomfort, and information provided by healthcare staff. Parents reported that they would prefer to know immediately if their child is at risk of dying; they also preferred to get as much information as possible from the healthcare team and thought that meeting with the healthcare team before making EOL decisions was pivotal. Parents place highest priorities on their child's likelihood of improvement, perception of their child's pain, and information provided by healthcare professionals in making EOL decisions.

What passive euthanasia is

BackgroundEuthanasia can be thought of as being either active or passive; but the precise definition of “passive euthanasia” is not always clear. Though all passive euthanasia involves the withholding of life-sustaining treatment, there would appear to be some disagreement about whether all such withholding should be seen as passive euthanasia.Main textAt the core of the disagreement is the question of the importance of an intention to bring about death: must one intend to bring about the death of the patient in order for withholding treatment to count as passive euthanasia, as some sources would indicate, or does withholding in which death is merely foreseen belong to that category? We may expect that this unclarity would be important in medical practice, in law, and in policy. The idea that withholding life-sustaining treatment is passive euthanasia is traced to James Rachels’s arguments, which lend themselves to the claim that passive euthanasia does not require intention to end life. Yet the argument here is that Rachels’s arguments are flawed, and we have good reasons to think that intention is important in understanding the moral nature of actions. As such, we should reject any understanding of passive euthanasia that does not pay attention to intent.Short conclusionJames Rachels’s work on active and passive euthanasia has been immensely influential; but this is an influence that we ought to resist.

Abstract P-409: EPIDEMIOLOGY OF DEATH IN PAEDIATRIC INTENSIVE CARE UNITS (PICUS) IN A DEVELOPING COUNTRY

Aims & Objectives: Decision making at end of life for children has been the most difficult experience for families and clinician. In depth study in this field is warranted to guide provision, funding and evaluation of palliative and bereavement care for both families and healthcare professionals. To describe the epidemiology of death among tertiary care PICUs in Malaysia. Methods Secondary analysis of prospectively collected data from patients (n=5,277) admitted to PICUs affiliated with the Paediatric Intensive Care Audit Registry (PEDICARE) between August 1, 2008 and December 31, 2015. Patients included were those who died in PICU. Results There were a total of 359 deaths, with crude mortality rate of 6.8% and SMR of 1.13. Ninety-nine (28.4%) patients died following withholding or withdrawal of treatment, 224 (62.4%) died despite maximal support, and 33 (9.2%) died following an unsuccessful resuscitation attempt. Seventy percent of all deaths occurred within the first week of admission. Patients who died beyond one week length-of-stay (LOS) were more likely to be of younger age (infant), cause of death due to liver failure, have prolonged use of mechanical ventilation and inotropes, and to have died following withholding of life-sustaining treatment. Four (26.7%) of brain dead patients died after one week. Conclusions The mode of death varies in relation to heterogeneity of practises and culture across all 3 PICUs. These data have implications for future quality improvement initiatives, especially around palliative care, end-of-life decision making, and organ donation.

Intracerebral hemorrhage in Intensive Care Unit: early prognostication fallacies. A single center retrospective study.

Intracerebral hemorrhage (ICH) admitted to Intensive Care is deem of poor prognosis. The aim of this study was to compare observed and predicted 30-day mortality and to evaluate long term functional outcome in a consecutive ICH cohort. Retrospective analysis of prospectively collected data of ICH patients managed in a Neuro-ICU from 2012 to 2015. Out of 136 consecutive patients, 34 (25%) had "withholding of life-sustaining treatment" (WLST) order and 102 (75%) received a "full treatment" (FT). WLST cohort: median (IQR): 72 (70-77) years old, Glasgow Coma Scale (GCS) 4 (3-4) at admission, ICH volume 114 cm3 (68-152); all patients died during neuro-ICU recovery, 28 (82%) patients had brain death diagnosis and 15 (54%) of these were organ donors. FT cohort: 67 (51-73) years old, GCS 9 (6-12) at admission, ICH volume 46 (24-90) cm3, neurosurgery for clot removal in 65 (64%) (P<0.05 vs. WLST cohort for each of previously listed variables); 13 (13%) patients died during neuro-ICU recovery, of these 11 (85%) patients had brain death diagnosis and 4 (36%) of them were organ donors. Overall 30-day observed mortality for FT group was 18% (95% CI: 11-26%). Patients with ICH Score 1, 2, 3, 4+ had 0%, 10%, 16% and 26% 30-day mortality, respectively (P<0.01 vs. ICH Score). Full treatment group 180-day mortality was 32% (95% CI: 24-42%). Modified Rankin Scale (mRS) after one year was ≤3 in 35 (35%), i.e. good recovery, and >3 in 64 (65%). Neurosurgery for clot removal was associated with a lower 30 and 180-day mortality (P=0.01 and P=0.03, respectively) and along with GCS at admission it was an independent significant prognostic factor. Mortality and functional outcome is less severe than predicted in patients with ICH receiving a full medical and/or surgical treatment.

Withdrawing clinically assisted nutrition and hydration (CANH) in patients with prolonged disorders of consciousness: is there still a role for the courts?

Currently, in England and Wales, Court of Protection’s Practice Directive 9E (PD9E) requires all cases of proposed withdrawal or withholding of life-sustaining treatment in relation to adults in a permanent...

Soins palliatifs au décours d’une réanimation néonatale : apports de la loi Léonetti et défis persistants

The 2005 enactment of the "Patients' rights and end-of-life care" act, known as the Leonetti law, has been accompanied by practical changes in the processes of withdrawal and withholding of active life-sustaining treatments. This law has also promoted the implementation of palliative care in perinatal medicine to avoid unreasonable therapeutic interventions and to preserve the dying patient's quality of life and human dignity. Recently, a new law has been voted by the French National Assembly and new reflections on the ethical aspects of the end of life in neonatal medicine should resume again within the French Society of Neonatology in the working group on ethical issues in neonatology. This is why it appears important to discuss the perceived benefits and the persistent difficulties related to the implementation of the Leonetti law in neonatology. Collegiality in the decision-making processes as well as withdrawal and withholding of life-sustaining treatments that were already present in the practices of many centers has been stipulated within a legal framework and promoted in clinical practice. It has brought serenity within perinatal nursing and medical teams. It has helped them face the always-difficult end-of-life situations with parents and deal with decision-making processes in an intense emotional climate. However, new questions inherent to the law have appeared. The most important ones concern the withholding of artificial nutrition and hydration, the time pressure in the management of the decision-making process, and the management of the duration of palliative care. Challenges remain in addressing various persistent ethical dilemmas such as the possible survival of newborns with significant brain lesions detected after the period of life-sustaining treatments that have allowed their survival. The new law carried by Mr. Clayes and Mr. Léonetti should provide answers to some of these ethical issues, but it would probably not solve all of them.

Assessing best interests in end-of-life care for a patient in a minimally conscious state

The legal basis and principles for the lawful withholding of life-sustaining treatment from people in a minimally conscious state have been laid out in the Supreme Court judgment in Aintree University Hospitals NHS Foundation Trust (Respondent) vs James (Appellant) [2013]. This was the first case under the Mental Capacity Act 2005 to come before the Supreme Court and hence it is of legal importance. The case involved a 68-year-old man who had multiple physical co-morbidities and who was diagnosed as being in a minimally conscious state. This article discusses the Supreme Court case and the approach taken by the Court of Protection and the Court of Appeal in applying the Mental Capacity Act 2005 when assessing whether withholding life-sustaining treatment is ever in a person9s best interests. It also outlines two similar cases from 2014. In so doing it demonstrates how the courts assess best interests in end-of-life care for people in minimally conscious states and how this differs legally from those in a persistent vegetative state.

Negotiated reorienting: A grounded theory of nurses’ end-of-life decision-making in the intensive care unit

BackgroundIntensive care units (ICUs) focus on treatment for those who are critically ill and interventions to prolong life. Ethical issues arise when decisions have to be made regarding the withdrawal and withholding of life-sustaining treatment and the shift to comfort and palliative care. These issues are particularly challenging for nurses when there are varying degrees of uncertainty regarding prognosis. Little is known about nurses’ end-of-life (EoL) decision-making practice across cultures. ObjectivesTo understand nurses’ EoL decision-making practices in ICUs in different cultural contexts. DesignWe collected and analysed qualitative data using Grounded Theory. SettingsInterviews were conducted with experienced ICU nurses in university or hospital premises in five countries: Brazil, England, Germany, Ireland and Palestine. ParticipantsSemi-structured interviews were conducted with 51 nurses (10 in Brazil, 9 in England, 10 in Germany, 10 in Ireland and 12 nurses in Palestine). They were purposefully and theoretically selected to include nurses having a variety of characteristics and experiences concerning end-of-life (EoL) decision-making. MethodsThe study used grounded theory to inform data collection and analysis. Interviews were facilitated by using key questions. The comparative analysis of the data within and across data generated by the different research teams enabled researchers to develop a deeper understanding of EoL decision-making practices in the ICU. Ethical approval was granted in each of the participating countries and voluntary informed consent obtained from each participant. ResultsThe core category that emerged was ‘negotiated reorienting’. Whilst nurses do not make the ‘ultimate’ EoL decisions, they engage in two core practices: consensus seeking (involving coaxing, information cuing and voice enabling); and emotional holding (creating time-space and comfort giving). ConclusionsThere was consensus regarding the core concept and core practices employed by nurses in the ICUs in the five countries. However, there were some discernible differences regarding the power dynamics in nurse–doctor relationships, particularly in relation to the cultural perspectives on death and dying and in the development of palliative care. The research suggests the need for culturally sensitive ethics education and bereavement support in different cultural contexts.

Experiences of Slovene ICU physicians with end-of-life decision making: a nation-wide survey.

BackgroundAdvances in intensive care medicine have enormously improved ability to successfully treat seriously ill patients. However, intensive treatment and prolongation of life is not always in the patient’s best interest, and many ethical dilemmas arise in end-of-life (EOL) situations. We aimed to assess intensive care unit (ICU) physicians’ experiences with EOL decision making and to compare the responses according to ICU type.Material/MethodsA cross-sectional survey was performed in all 35 Slovene ICUs, using a questionnaire designed to assess ICU physician experiences with EOL decision making, focusing on limitations of life-sustaining treatments (LST).ResultsWe distributed 370 questionnaires (approximating the number of Slovene ICU physicians) and 267 were returned (72% response rate). The great majority of ICU physicians reported using do-not-resuscitate (DNR) orders (97%), withholding LST (94%), and withdrawing antibiotics (86%) or inotropes (95%). Fewer ICU physicians reported withdrawing mechanical ventilation (52%) or extubating patients (27%). Hydration was reported to be only rarely terminated (76% of participants reported never terminating it). In addition, 63% of participants had never encountered advance directives, and 39% reported to “never” or “rarely” participating in decision making with relatives of patients. Nurses were reported to be “never” or “rarely” involved in the EOL decision making process by 84% of participants.ConclusionsLimitation of LST was regularly used by Slovene ICU physicians. DNR orders and withholding of LST were the most commonly used measures. Hydration was only rarely terminated. In addition, use of advance directives was almost non-existent in practice, and the patients’ relatives and nurses only infrequently participated in the decision making.

Nonphysician-Assisted Suicide in Switzerland

In general, legal responses to endof-life issues are not very different in Switzerland than in most European countries. For instance, active euthanasia (i.e., killing on request) is illegal, although it is treated as a lesser offense than murder or manslaughter. Article 114 of the Swiss Penal Code reads, ‘‘Every person who, for honourable reasons, especially mercy, kills another person on his or her serious and pressing request shall be punished by imprisonment for a maximal term of three years or with a fine.’’ Also, like in most European countries, the administration of medication (for instance, morphine) to relieve serious pain of a terminal patient, even though it may lead to the unintended consequence of hastening his or her death, is accepted, in both moral and legal terms. Similarly, like in many other countries, the withdrawal or withholding of life-sustaining treatments, even if they are not covered by any specific legal provision, is not treated as a criminal offense provided that certain conditions are fulfilled. The peculiarity of Switzerland regarding end-of-life issues only relates to assisted suicide. This practice, which is permitted, has two significant differences when compared to the situation in the other (few) European countries that allow it: 1) Nonphysician-assisted suicide is permitted. Whereas in the Netherlands and Belgium only physicians are allowed to assist in a suicide, in Switzerland this assistance is providedby(nonphysician)volunteers working for nonprofit organizations. The role of doctors is limited to prescribing the lethal drug and assessing the patient’s decisional capacity; they do not perform the assistance in the suicide themselves. In this regard, the practice of assisted suicide in Switzerland is similar to the one in the U.S. state Oregon. 2) Oneneednothaveaparticularmedical condition (such as a terminal illness or an unbearable suffering) to request assistance with suicide. The only requirement is that the individual must have decisional capacity, because in the absence of it his or her act cannot be considered a ‘‘suicide’’ in legal terms. In fact, at present, according to a recent study, around 25% percent of people who die by assisted suicide in Switzerland do not have any serious or terminal illness but are just old, or are simply ‘‘tired of life.’’

Treatment Decisions After Severe Stroke

Stroke demands our attention because it is common, disabling, and deadly. One in 15 patients requires mechanical ventilation on admission, 1 in 20 patients is discharged from the acute care hospital with a feeding tube, and 1 in 5 patients requires institutional care at 3 months after stroke.1 Most patients with severe stroke who die, do so in the setting of withdrawal of life-sustaining treatment (LST),2 and this decision is typically made by physicians who predict a poor outcome and surrogates who are asked to articulate the patient’s preferences3: "she would not want to live like that." When prognosis is certain and the outcome unacceptable, the decision to withdraw or withhold LST may be relatively straightforward, although emotionally challenging. In most severe strokes, however, decisions are made when prognosis is uncertain and when what constitutes an acceptable outcome is unknown. In this article, we explore the uncertainties and biases that influence these life-and-death decisions. Such biases can lead to errors in decision making and ultimately the overuse or underuse of LST. Hence, the need is urgent to understand better the factors that contribute to optimal -decision making.4 Surviving a severe stroke means living with disability. Treatment decisions, thus, frequently involve trade-offs.5 Three typical preference-sensitive decisions after severe stroke are mechanical ventilation, artificial nutrition, and surgical decompression for hemorrhagic or ischemic strokes with life-threatening mass effect. All of these LSTs reduce the risk of death but increase the chance of survival.6–8 Although one individual may choose life at all costs, even when evidence predicts severe disability, another may refuse LSTs despite a prospect of surviving with a modest deficit, trading off the possibility of survival in an undesirable health state for the more desirable outcome of death. In the acute setting, withdrawal …

Physician Reimbursement for Critical Care Services Integrating Palliative Care for Patients Who Are Critically Ill

Patients with advanced illness often spend time in an ICU, while nearly one-third of patients with advanced cancer who receive Medicare die in hospitals, often with failed ICU care. For most, death occurs following the withdrawal or withholding of life-sustaining treatments. The integration of palliative care is essential for high-quality critical care. Although palliative care specialists are becoming increasingly available, intensivists and other physicians are also expected to provide basic palliative care, including symptom treatment and communication about goals of care. Patients who are critically ill are often unable to make decisions about their care. In these situations, physicians must meet with family members or other surrogates to determine appropriate medical treatments. These meetings require clinical expertise to ensure that patient values are explored for medical decision making about therapeutic options, including palliative care. Meetings with families take time. Issues related to the disease process, prognosis, and treatment plan are complex, and decisions about the use or limitation of intensive care therapies have life-or-death implications. Inadequate reimbursement for physician services may be a barrier to the optimal delivery of high-quality palliative care, including effective communication. Appropriate documentation of time spent integrating palliative and critical care for patients who are critically ill can be consistent with the Current Procedural Terminology codes (99291 and 99292) for critical care services. The purpose of this article is to help intensivists and other providers understand the circumstances in which integration of palliative and critical care meets the definition of critical care services for billing purposes.

연명치료중단과 유보 결정에 대한 한국 중환자 전담의사 인식과 실행

Purpose: This study was performed to evaluate both the attitudes and practices of critical care physicians in Korean ICUs regarding end-of-life care decisions as well as the factors that influence those attitudes and practices. Methods: A questionnaire was developed and delivered to 100 members of the Korean Society of Critical Care Medicine in September 2007. The questionnaire was divided into six parts including personal information, decision-making processes, the withdrawing and withholding of life-sustaining treatment, informed consent, consultation with ethics committees, and guidelines. Results: Eighty eight responses from 53 different institutions were received. The results of the questionnaire include the following. There was a significant difference between the attitude and practices of respondents concerning family consent and patient’s consent. Attitudes toward patient and family consent differed significantly according to the clinical experiences of the respondents (p&lt;.05). There was a significant difference between the attitudes and practices of respondents concerning how often caregivers effectively communicated with patients and family members. Attitudes toward family participation in decision-making processes differed significantly according to the respondents’ gender. There was also a significance difference between the attitudes and practices of respondents regarding the withdrawal of life-sustaining treatment. Attitudes and practices on this issue varied according to the type of ICU where the respondents worked and their medical specialty. Practices concerning informed consent for “do not resuscitate” orders varied significantly according to respondent’s age and type of ICU. Finally, attitudes on the participation of ethics committees in decision-making processes varied significantly according to respondent’s clinical experiences (p&lt;.05). Conclusions: This study found significant differences in the attitudes and practices of critical care physicians in Korean ICUs concerning end-of-life care decisions and the withdrawing and withholding of life-sustaining treatment. The study also found that the factors influencing these attitudes and practices include age, specialty, clinical experiences, and the types of ICU in which physicians work. However, there are some limitations in generalizing these findings.