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Global comparison of communication of end-of-life decisions in the intensive care unit
Article indépendant
BACKGROUND: Prolonging life in the intensive care unit (ICU) is increasingly possible, so decisions to limit life-sustaining therapies are frequently made and communicated to patients and families/surrogates. Little is known about worldwide communication practices and influencing factors.
RESEARCH QUESTION: Are there regional differences in end-of-life communication practices in ICUs worldwide?
STUDY DESIGN AND METHODS: This analysis of data from a prospective, international study, specifically addressed end-of-life communications in consecutive patients who died or had limitation of life-sustaining therapy over 6 months in 199 ICUs in 36 countries, grouped regionally. End-of-life decisions were recorded for each patient and ethical practice was assessed retrospectively, for each ICU, using a 12-point questionnaire developed previously.
RESULTS: Of 87,951 patients admitted, 12,850 died or had a limitation of therapy (14.6%). Of these, 1,199 (9.3%) were known to have an advance directive, and in 6,456 (50.2%) patient wishes were elicited. Limitations of life-sustaining therapy occurred in 10,401 (80.9%) patients, 1,970 (19.1%) of whom had mental capacity at the time, and was discussed with 1,507 (14.5%) patients and 8,461 (81.3%) families. Where no discussions with patients occurred (8,710) this was primarily because of a lack of mental capacity in 8,114 (93.2%) and with families (1,622) because of unavailability (720 [44.4%]). Regional variation was noted for all endpoints. In generalized estimating equations analyses, the odds for discussions with the patient/family increased by 30% (odds ratio: 1.30, 95% confidence interval: 1.18-1.44; P<0.001) for every one-point increase of the Ethical Practice Score, and by 92% (odds ratio: 1.92, 95% confidence interval: 1.28-2.89; P=0.002) in the presence of an advance directive.
INTERPRETATION: End-of-life communication with patients and families/surrogates varies markedly in different global regions. GEE analysis supports the hypothesis that communication may increase with ethical practice and an advance directive. Greater effort is needed to align treatment with patients' wishes.
http://dx.doi.org/10.1016/j.chest.2022.05.007
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