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Department of Anesthesiology and Critical Care Medicine Hadassah Medical Center. End of life care around the world Charles Sprung MD. OPTIONS AT THE END OF LIFE. FULL CONTINUED CARE. WITHHOLDING TREATMENT. WITHDRAWING TREATMENT. ACTIVE LIFE ENDING PROCEDURES. END OF LIFE DECISION MAKING.

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slide1

Department of Anesthesiology and Critical Care MedicineHadassah Medical Center

End of life care around the worldCharles Sprung MD

options at the end of life
OPTIONS AT THE END OF LIFE

FULL CONTINUED CARE

WITHHOLDING TREATMENT

WITHDRAWING TREATMENT

ACTIVE LIFE ENDING PROCEDURES

slide3

END OF LIFE DECISION MAKING

  • Differences between America, Europe and Israel
  • Religious and regional differences
  • Attitudes of patients, families, physicians and nurses
  • The Israeli Dying Patient Act, 2005
slide4

WHY STUDY ICU DEATHS?

  • Approximately 20% of patients dying in the United States die in ICUs
  • Angus DC, et al. Crit Care Med 2004; 32: 638-643
  • Of patients who die in the hospital, approximately half are cared for in an ICU within 3 days of their death
  • Support Investigators. JAMA 1996;274:1591-1598
slide5

END OF LIFE DECISION MAKING

The majority of patients dying in ICUs do so after the decision to limit therapy

Levin PD. Crit Care Med 2003; 31:S1-S4

slide6

END OF LIFE DECISION MAKING IN DIFFERENT COUNTRIES

  • Majority of physicians withhold and withdraw treatments in North America and Europe
  • Prendergast TJ. Am J Resp CCM 1998; 158:1163
  • Sprung CL. JAMA 2003;290:790
  • Physicians in Holland and Belgium perform active euthanasia
  • Hendin H. JAMA 1997; 277:1720
  • Dellens L. LANCET 2000; 356:1806
  • Physicians withhold and do not withdraw therapies
  • Eidelman LA. Intensive Care Med 1998;24:162-166
slide7

END OF LIFE DECISION MAKING

  • Wide variations between countries, within countries, within cities and even in the same ICU
  • Explained by different physician values
  • Cook DJ. JAMA 1995;273:703-708
slide8

END OF LIFE DECISION MAKING

  • North American approach Autonomy
  • European approach Paternalistic
slide9

END OF LIFE DECISION MAKING

FULL CARE + CPR 26% (4 - 79%)

FULL CARE - NO CPR 24% (0 - 83%)

TREATMENT WITHHELD 14% (0 - 67%)

TREATMENT WITHDRAWN 36% (0 - 79%)

Prendergast TJ. Am J Resp CCM 1998; 158:1163

slide10

END OF LIFE DECISION MAKING IN DIFFERENT COUNTRIES

  • Transatlantic divergence as to who has the final decision if the patient is incompetent
  • Whilst the views of those close to the patient are an important factor..the treatment decision is not their right …decision will be made by the clinician- Brit Med Assoc
  • Family and relatives should be informed…the family has no decision-making capability- Belgian CC Soc
  • ACCP, ATS, SCCM support shared decision making model and none advocate ultimate decision with doctor
  • Carlet J. Intensive Care Med 2004; 30:770-84
slide11

SERIOUS PROBLEMS WITH END OF LIFE CARE

  • One half of dying patients had moderate or severe pain during most of their final 3 days
  • Communication between physicians and patients was poor; only 41% of patients reported talking to their doctors about prognosis or CPR
  • Physicians misunderstood patient preferences regarding CPR in 80% of cases
  • Doctors did not implement patient desires; no DNR in 50% of patients wanting CPR withheld
  • Support Investigators JAMA 10995; 274:1591
slide12

Department of Anesthesiology and Critical Care MedicineHadassah Medical Center

ETHICUS: PROSPECTIVE, OBSERVATIONAL STUDY OF END OF LIFE DECISION MAKING IN EUROPEAN INTENSIVE CARE UNITSSprung et al. JAMA 2003;290:790

מדינת ישראל

STATE OF ISRAEL

slide13

31,417

4,280

32

4,248

STUDY POPULATION

Included: all consecutive patients who died or had limitation

of treatment (WH, WD, SDP) from 1.1.1999 - 30.6.2000

Screened patients

Total study patients

Excluded patients

Study patients

37 centres

17 countries

(13.5%)

slide15

n (%)

832 (20)

330 (8)

1594 (37)

1398 (33)

94 (2)

4248 (100)

RANGE (%)

7 - 48

0 - 15

16 - 70

5 - 69

0 - 19

CPR

BRAIN DEATH

WITHHOLD

WITHDRAW

SDP

TOTAL

END-OF-LIFE CATEGORIES

slide16

END OF LIFE DECISION MAKING

  • Differences between America, Europe and Israel
  • Religious and regional differences
  • Attitudes of patients, families, physicians and nurses
  • The Israeli Dying Patient Act, 2005
slide17

DOCTOR RELIGIONS

NUMBER (%)

1554 (37)

957 (22)

883 (21)

393 (9)

330 (8)

38 (1)

67 (1)

26(1)

4248 (100)

RELIGION

Catholic

None

Protestant

Jewish

Greek Orthodox

Islam

Unknown

Other

TOTAL

Sprung CL. Intensive Care Med 2007: 33:1732

end of life decision based on doctor s religion
END OF LIFE DECISION BASED ON DOCTOR’S RELIGION

RELIGION CPR WITHDRAWING WITHHOLDINGNUMBER (%)NUMBER (%)NUMBER (%)

CATHOLIC 317 (22) 648 (46) 450 (32)

PROTESTANT 84 (10) 390 (46) 380 (45)

GREEK ORTH 109 (39) 37 (13) 131 (47)

JEWISH 60 (16) 58 (16) 251 (68)

ISLAM 14 (37) 9 (24) 15 (40)

NONE 209 (24) 331 (38) 338 (39)

TOTAL 793 (21) 1473 (38) 1565 (41)

Sprung CL. Intensive Care Med 2007: 33:1732

median time from icu admission to first limitation by doctor religion
MEDIAN TIME FROM ICU ADMISSION TO FIRST LIMITATION BY DOCTOR RELIGION

RELIGION MEDIAN TIMES (days)

CATHOLIC 4.0 (IQR:11.2)

PROTESTANT 1.3(IQR:4.6)

GREEK ORTHODOX 7.6(IQR:13.9)

JEWISH 3.6 (IQR:12.1)

ISLAM 4.1 (IQR:6.9)

NONE 2.4 (IQR:7.5)

TOTAL 2.9 (IQR:16.8) p < 0.0001

Sprung CL. Intensive Care Med 2007: 33:1732

patient was mentally competent when end of life decision was made
PATIENT WAS MENTALLY COMPETENT WHEN END OF LIFE DECISION WAS MADE

Number%

No 3360 79

Yes 195 5

Not Applicable 693 16

TOTAL 4248 100

Cohen S. Intensive Care Med 2005; 31:1215

information recieved about patients wishes
INFORMATION RECIEVED ABOUT PATIENTS’ WISHES

Number %

No 2702 64

Yes 850 20

Not Applicable 694 16

TOTAL 4246 100

Cohen S. Intensive Care Med 2005; 31:1215

information about patients wishes by religion
INFORMATION ABOUT PATIENTS’ WISHES BY RELIGION

RELIGION INFORMATION

CATHOLIC 13%

PROTESTANT 28%

GREEK ORTHODOX 21%

JEWISH 22%

ISLAM 5%

NONE 24%

TOTAL 20%

p < 0.0001

Sprung CL. Intensive Care Med 2007: 33:1732

end of life decision discussed with family
END-OF-LIFE DECISION DISCUSSED WITH FAMILY

Number %

No 974 32

Yes 2107 68

TOTAL 3081 100

discussions based on physician religion
Prospective study of deaths in 37 ICUs in 17 countries

3086 patients with limitation of treatment

Discussions Based on Physician Religion

Sprung, ICM 2007; 33:1732

slide25

END OF LIFE DECISION MAKING

  • Catholic physicians were less likely to withhold or withdraw therapies
  • Vincent JL. Crit Care Med 1999; 27:1626
  • SCCM Ethics Committee. Crit Care Med 1992;20:320
  • Jewish physicians reported more likely to withhold or withdraw therapies
  • SCCM Ethics Committee. Crit Care Med 1992;20:320
  • Descriptive Israeli study demonstrated that Jewish physicians withheld and did not withdraw therapies
  • Eidelman LA. Intensive Care Med 1998;24:162-166
slide26

END OF LIFE DECISION MAKING

  • Ethnic beliefs may slowly be altered by exposure to different cultures
  • Process of acculturation- ethnic origin is tempered by the host society
  • Levin PD. Crit Care Med 2003; 31:S1-S4
slide27

END OF LIFE DECISION MAKING

  • Differences between America, Europe and Israel
  • Religious and regional differences
  • Attitudes of patients, families, physicians and nurses
  • The Israeli Dying Patient Act, 2005
slide28

END-OF-LIFE CATEGORIES BY REGION

1600

CPR

BRAIN DEATH

WITHHOLD

1200

WITHDRAW

SDP

800

400

0

NORTHERN

CENTRAL

SOUTHERN

TOTAL

Sprung CL. JAMA 2003;290:790

median time from icu admission to first limitation by region
MEDIAN TIME FROM ICU ADMISSION TO FIRST LIMITATION BY REGION

REGION MEDIAN TIMES (days)

NORTHERN 1.6 (IQR:4.8)

CENTRAL3.3 (IQR:11.0)

SOUTHERN 5.7 (IQR:12.3)

TOTAL 2.8 (IQR:9.2)

p < 0.001

Sprung CL et al. JAMA 2003;290:790

median times from first limitation to death
MEDIAN TIMES FROM FIRST LIMITATION TO DEATH

REGION MEDIAN TIMES (HRS)

NORTHERN 11.4 (IQR: 12.2)

CENTRAL 22.0 (IQR: 74.2)

SOUTHERN 16.0 (IQR: 57.9)

TOTAL 14.7 (IQR: 51.0)

p < 0.0001

Sprung CL et al. JAMA 2003;290:790

written orders documentation for dnr by region
WRITTEN ORDERS & DOCUMENTATION FOR DNR BY REGION

REGION WRITTEN ORDERS DOCUMENTATION

NORTHERN1029/1300- 79% 1141/1301- 88%

CENTRAL702/898- 78% 689/897- 77%

SOUTHERN260/883- 29% 304/881- 35%

TOTAL1991/3081- 65% 2134/3079- 69%

p < 0.0001 p < 0.0001

Cohen S. Intensive Care Med 2005; 31:1215

information concerning patient wishes by region
INFORMATION CONCERNING PATIENT WISHES BY REGION

REGION NORTHERN CENTRAL SOUTHERN

461/1505- 31% 188/1209-16% 201/1534-13%

p < 0.0001

Cohen S. Intensive Care Med 2005; 31:1215

discussions with patients and families by regions
DISCUSSIONS WITH PATIENTS AND FAMILIES BY REGIONS

REGION PATIENT FAMILY

NORTHERN58/1303- 5% 1093/1303- 84%

CENTRAL29/900- 3% 597/900- 66%

SOUTHERN9/883- 1%417/883- 47%

TOTAL96/3086- 3% 2107/3086- 68%

p < 0.0001 p < 0.0001

Cohen S. Intensive Care Med 2005; 31:1215

relieving suffering or intentionally hastening death
RELIEVING SUFFERING OR INTENTIONALLY HASTENING DEATH?

Findings in the Ethicus study that doses of opioids and benzodiazepines reported for active SDP with the intent to cause death were in the same range as those used for symptom relief in earlier studies and that times to death were similar for SDP and WD patients, demonstrate that the distinction between treatments to cause death and to relieve suffering in dying patients may be unclear

Sprung CL. Crit Care Med 2008; 36: 8-13

options at the end of life36
OPTIONS AT THE END OF LIFE

FULL CONTINUED CARE

WITHHOLDING TREATMENT

WITHDRAWING TREATMENT

ACTIVE LIFE ENDING PROCEDURES

therapeutic limitations in saps3 study
Therapeutic Limitations in SAPS3 Study

Azoulay E. Intensive Care Med 2009;35:623-630

variations in decisions to flsts
Variations in Decisions to FLSTs
  • Personal physician characteristics
  • Case-mix and co-morbidities
  • Experience
  • Gender
  • Specialty or time working in ICUs
  • Religious beliefs and cultural background
  • Organizational factors
  • Presence of full time intensivist

Azoulay E. Intensive Care Med 2009;35:623-630

therapeutic limitations in saps3 study39
Therapeutic Limitations in SAPS3 Study
  • FLST decisions more common in hospitals without emergency departments, in smaller ICUs & ICUs with lower nurse-to-patient ratios and more physicians per ICU bed.
  • DFLSTs were more common when intensivists were present only during weekdays, when multidisciplinary meetings were held, and when nurses and intensivists performed clinical rounds together.
  • DFLSTs were less common in ICUs that had at least one full time intensivist and in those with intensivists available at night and over weekends.

Azoulay E. Intensive Care Med 2009;35:623-630

therapeutic limitations in saps3 study40
Therapeutic Limitations in SAPS3 Study

cancer patients

mechanical ventilation

FLST

mortality

Azoulay E. Intensive Care Med 2009;35:623-630

slide41

END OF LIFE DECISION MAKING

  • Differences between America, Europe and Israel
  • Religious and regional differences
  • Attitudes of patients, families, physicians and nurses
  • The Israeli Dying Patient Act, 2005
slide42

Department of Anesthesiology and Critical Care MedicineHadassah Medical Center

ETHICATT: SYSTEMATIC STUDY OF GENERAL ETHICAL PRINCIPLES INVOLVED IN END OF LIFE DECISIONS FOR PATIENTS IN EUROPEAN INTENSIVE CARE UNITSSprung CL. Intensive Care Med 2007: 33:104

מדינת ישראל

STATE OF ISRAEL

ethicatt study
ETHICATT STUDY
  • Empirical study of the attitudes of doctors, nurses, patients, and families involved in end of life decisions in different European countries
  • Performed in Czechia, Israel, the Netherlands, Portugal, Sweden and the UK
  • Criteria for inclusion: ICU doctors and nurses, patients previously hospitalized in the ICU within the last 12 months for more than 3 days and who could complete the questionnaire, and family members who were present most in the ICU during the patient’s hospitalization
  • Questionnaires completed 3-6 months after patient was in ICU
ethicatt study44
ETHICATT STUDY
  • Demographic data: country, age, sex, marital status, children, religion, religiosity, income, years of practice and types of practice for doctors and nurses
  • 1899 questionnaires were completed by 528 doctors and 629 nurses who work in ICUs, 330 patients who survived ICU, 412 families of patients dying or surviving their ICU stay
end of life decisions
END OF LIFE DECISIONS
  • Do patients and families want to be in ICUs, undergo CPR or mechanical ventilation?
  • Do patients or families want to have active euthanasia?
  • Do doctors want the same therapies for themselves as they want for their patients?

Sprung CL. Intensive Care Med 2007: 33:104

terminal illness n
TERMINAL ILLNESS: N (%)

DOCTOR NURSE FAMILY PATIENT

ICUadmission 98(19) 130(22) 219(55) 198(62)

CPR 30(6) 61(10) 173(54) 181(45)

Ventilator 37(7) 70(12) 156(49) 155(39)

Sprung CL. Intensive Care Med 2007: 33:104

terminal illness active euthanasia for pain number
TERMINAL ILLNESS: ACTIVE EUTHANASIA FOR PAIN Number (%)

CountryDrs Nurses Patients Families

Sweden 16(15) 26(21) 28(45) 50(59)

England 13(18) 39(36) 17(46) 16(52)

Holland 31(30) 40(35) 25(64) 41(67)

Czechia 49(56) 44(56) 7(35) 13(46)

Portugal 25(54) 54(59) 23(34) 51(51)

Israel 37(42) 41(53) 42(44) 47(48)

TOTAL171(34) 244(41) 142(44) 218(54)

biblical ethics
BIBLICAL ETHICS
  • The value and sanctity of human life is infinite and beyond measure
  • Therefore, any part of life is of the same worth
  • Active or passive euthanasia is prohibited
  • The omission of life-sustaining therapies is allowed
  • An act that hasten’s a patients death, no matter how laudable the intentions, is equated with murder
the dying patient act 2005
THE DYING PATIENT ACT, 2005
  • The new Israeli law is the first law worldwide whose scope is the regulation of medical care at the end of life
  • The law also contains novel concepts and approaches to the care of the terminally ill

Steinberg A. Intensive Care Med 2006;32:1234

Barilan YM. Perspect Biol Med. 2007;50:557-71

the dying patient act 200551
THE DYING PATIENT ACT, 2005
  • The Law is based upon an expert consensus process
  • The Law provides mechanisms for advance medical directives, the appointment of surrogate decision-makers and accepting family information
  • A National bank of advance medical directives
  • Palliative care as a citizen’s right
  • Clear guidelines for physicians to know what is permitted and prohibited
  • The appointment of a senior physician with clear directives of his responsibilities- documentation and communication
  • Dispute resolution with the establishment of local and a National Ethics Committee to avoid the courts
the dying patient act 200552
THE DYING PATIENT ACT, 2005
  • The Law prohibits stopping continuous life-sustaining therapies (ventilator) because this is viewed as an act that shortens life
  • The Law permits stopping intermittent life-sustaining therapies (intubation, dialysis, chemotherapy)
  • Terminating intermittent life-sustaining treatments is viewed as an omission of the first or next treatment rather than commission of an act of withdrawal

Steinberg A. Intensive Care Med 2006;32:1234

the dying patient act 2005 biblical ethics or halacha
THE DYING PATIENT ACT, 2005 BIBLICAL ETHICS OR HALACHA
  • These decisions are founded in the Jewish legal system (Halacha) where there is no obligation to actively prolong pain and suffering of a dying patient but any action that intentionally and actively shortens life is prohibited
  • The withdrawal of a ventilator (a continuous form of treatment) is considered an act that shortens life and is therefore forbiddenSteinberg A. Intensive Care Med 2006;32:1234
the dying patient act 200554
THE DYING PATIENT ACT, 2005
  • As continuing unwanted ventilatory treatment would prolong suffering, the Law allows the possibility of changing the ventilator from a continuous form of treatment to an intermittent form
  • This is performed by connecting a timer and allowing the ventilator to stop intermittently

Steinberg A. Intensive Care Med 2006;32:1234

the dying patient act 2005 timer attributes
THE DYING PATIENT ACT, 2005 TIMER ATTRIBUTES

The “timer”, as a pragmatic solution would enable doctors to honor the wishes of patients and families without termination of continuous treatment of a dying patient which may cause his death !

Ravitsky V. BMJ  2005;330:415-417

the dying patient act 200556
THE DYING PATIENT ACT, 2005
  • The Law is based on the Jewish legal concept that not only the end has to be morally justified (the death of a suffering terminally ill patient) but also that the means to achieve the end must be morally correct
  • This innovative approach of a timer on a ventilator is also psychologically helpful to health-care providers who have problems executing the wishes of the patient and withdrawing ventilators

Steinberg A. Intensive Care Med 2006;32:1234

ethicus probability of death over time
ETHICUS: PROBABILITY OF DEATH OVER TIME

WithholdWithdrawalSDP

  • 24 Hours 50% 80% 93%
  • 48 Hours 61% 89% 97%
  • 72 Hours 68% 93% 99%
  • 7 Days 77% 97% 100%

Sprung et al. JAMA 2003;290:790

the israeli dying patient law
THE ISRAELI DYING PATIENT LAW
  • The present Israeli solution is contrary to most Western countries where no distinctions are made between continuous and intermittent therapies, actions and omissions, withholding and withdrawing treatments or nutrition and other treatments

Steinberg A. Intensive Care Med 2006;32:1234

slide61

CONCLUSIONS- 1

  • End of life decisions commonly occur in North American and European ICUs
  • Limitations and variations appear similar in North American and European ICUs
  • Communication, decision making and documentation are very different in North America and Europe
  • End of life practices are different for physicians of different religions
slide62

CONCLUSIONS- 2

  • More withdrawal for Catholic, Protestant or physicians with no religions
  • More CPR for Greek Orthodox and Muslim doctors
  • Less discussions for Greek Orthodox and Muslim doctors
  • Differences in religions in various studies may relate to acculturation
  • Regional differences are likely due to diverse religions
slide63

CONCLUSIONS- 3

  • Distinction between treatments to cause death and to relieve suffering in dying patients may be unclear
  • Patients and families desire more aggressive therapies than doctors and nurses
  • Patients and families desire active euthanasia for pain as do doctors and nurses
slide64

CONCLUSIONS- 4a

  • The Israeli Dying Patient Act contains novel concepts and approaches to the care of the terminally ill which were developed by consensus and conform to Halacha
  • Timers to change ventilators from a continuous to an intermittent treatment
  • Palliative care as a citizen’s right
  • A National Bank of advance medical directives
welpicus
WELPICUS
  • Welpicus- Consensus Guidelines for Worldwide End of Life Practice for Patients in Intensive Care Units
  • Worldwide ICU societies have participated in bringing together experts from at least 27 countries to develop Worldwide consensus for end of life practices