ORIGINAL INVESTIGATION International Differences in End-of-Life Attitudes in the Intensive Care Unit Results of a Survey Arino Yaguchi, MD; Robert D. Truog, MD; J. Randall Curtis, MD; John M. Luce, MD; Mitchell M. Levy, MD; Christian Mélot, MD; Jean-Louis Vincent, MD, PhD Background: Important international differences ex- tral Europe, whereas oral orders took preference in South- ist in attitudes toward end-of-life issues in the intensive ern Europe, Turkey, and Brazil. One third of Japanese care unit. physicians said that they would not apply do-not- resuscitate orders. Most participants from Japan, Tur- Methods: A simple questionnaire survey was sent by key, the United States, Southern Europe, and Brazil chose e-mail to participants at an international meeting on in- to treat the hypothetical patient with antibiotics if he/ tensive care medicine. Respondents were asked to choose she developed septic shock, whereas in Northern Eu- 1 of 3 to 5 possible answers for each of 4 questions re- rope, Central Europe, Canada, and Australia, terminal lated to the treatment of a hypothetical patient in a veg- withdrawal of mechanical ventilation and extubation were etative state due to anoxic encephalopathy after cardiac the more commonly chosen responses. arrest with no family and no advance directives. Conclusions: In countries where intensive care medi- Results: From 3494 valid addresses, 1961 complete ques- cine is relatively well developed, considerable differ- tionnaires (56%) were received from 21 countries. Sixty- ences remain in physicians’ attitudes toward end-of-life two percent of physicians from Northern and Central Eu- rope said they involved nurses in end-of-life discussions care in the intensive care unit. Substantial work re- compared with only 32% of physicians in Southern Eu- mains if an international consensus on these issues is to rope, 38% in Brazil, 39% in Japan, and 29% in the United be reached. States (PϽ.001 for all comparisons). Written do-not- resuscitate orders were preferred in Northern and Cen- Arch Intern Med. 2005;165:1970-1975 ISCUSSIONS ABOUT END- ing to the variability of these end-of-life of-life issues have be- decisions and the difficulty in achieving come common, espe- an international consensus on these is- Author Affiliations: cially in the Western sues. Numerous reports exist on this Department of Intensive Care medical literature. Ad- topic,4-13 and several surveys have been Medicine, Erasme Hospital, vances in medical technology and thera- conducted2,14-25; however, these surveys Free University of Brussels, D Brussels, Belgium (Drs Yaguchi, pies enable more lives to be saved but were limited to national or geographic re- Mélot, and Vincent); sometimes may merely prolong the dy- gions, and no large international survey has Department of Anesthesia and ing process. Recent studies1,2 have shown been performed. As previous studies have Medical Ethics, Harvard that the exact timing of death is often un- shown,14,17,18,20 substantial differences ex- Medical School, Children’s der the control of the physicians who care ist among European countries. Further- Hospital, Boston, Mass for the patient. This is particularly true in more, the guidelines in the United States26 (Dr Truog); Division of the intensive care unit (ICU),3 where death are also different from those within Eu- Pulmonary and Critical Care 27,28 Medicine, University of is commonly preceded by decisions not to rope. Although some would defend the Washington, Harborview start aggressive therapy (withholding) or need for the development of an interna- Medical Center, Seattle to discontinue life-sustaining therapy tional consensus or a global system of eth- (Dr Curtis); Department of (withdrawing). The question of who ics,3 this may not be achievable or even de- Medicine and Anesthesia, should be responsible for decision mak- sirable. In a recent survey of physicians University of California, San ing is a difficult issue; the patient is often involved in end-of-life care in 6 Euro- Francisco (Dr Luce); and unable to participate in this decision, and pean countries and Australia, Miccinesi et Department of Critical Care, 29 Rhode Island Hospital, Brown the roles of the medical team, the rela- al reported that country was the stron- University, Providence tives, and the legal system are highly vari- gest determinant of physician attitude to- (Dr Levy). able in different parts of the world, add- ward end-of-life decisions, although the in- (REPRINTED) ARCH INTERN MED/ VOL 165, SEP 26, 2005 WWW.ARCHINTERNMED.COM 1970 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 dividual physician characteristics of age, religious beliefs, sex, and previous experience with dying patients were Table 1. The Questionnaire also strong determinants. Other studies11,14,17,18,29,30 have shown the strong influence of religion, culture, race, le- Case Scenario gal background, social factors, and tradition on atti- A 55-year-old woman was resuscitated from cardiac pulmonary arrest tudes toward end-of-life issues. In addition, these issues due to cardiac ischemic disease and admitted to the intensive care 11,14,17 unit (ICU) with severe postanoxic lesions. Twenty-four hours later, are influenced by and change with temporal trends, she has decerebration movements and the evoked potentials are as illustrated by the Hippocratic Oath, which recog- absent. The consensus (including the senior neurologist) is that her nized the importance of the principles of beneficence, non- best possible outcome is a persistent vegetative state. She has no maleficience, and medical futility but did not discuss au- close relative or advance directive. tonomy or distributive justice. During the last 4 decades, Question 1. Which process do you follow to decide on the treatment autonomy and distributive justice have become increas- for this patient in the ICU? ingly predominant. 1. Decide by yourself. To better understand the international differences in 2. Decide after a consensus is reached with other physicians. 3. Decide after discussions involving other physicians and nurses. end-of-life decisions in the ICU, we conducted a simple 4. Refer to the ethical committee in your hospital. international survey by e-mail. The aim of the study was 5. Refer to court. to record current end-of-life attitudes of ICU physicians Question 2. Is this process likely to result in do-not-resuscitate (DNR) in those parts of the world where the practice of inten- orders being applied in the event of recurrent cardiac arrest? sive care medicine is fairly well developed. 1. Yes, written DNR orders. 2. Yes, verbal DNR orders. 3. No. METHODS Question 3. The patient remains absolutely stable for 5 days and, although still receiving mechanical ventilation, can breathe STUDY DESIGN spontaneously. What would be the usual strategy in your institution? 1. Keep the patient in the ICU (with or without tracheostomy) and A list of e-mail addresses of individuals who had requested in- start further interventions if a complication occurs. formation regarding the International Symposium on Inten- 2. Keep the patient in the ICU (with or without tracheostomy)— sive Care and Emergency Medicine was provided by the meet- “wait and see”—but withhold therapy if a complication occurs. ing’s secretariat. This symposium (www.intensive.org), held 3. Keep the patient in the ICU and start increasing doses of every year in Brussels, Belgium, is one of the largest interna- morphine or sedatives with the intent to decrease ventilatory tional meetings in this field, with close to 5000 participants at- conditions (“terminal weaning”). tending each year. We limited our list of addresses to physi- 4. Perform a tracheostomy and transfer the patient to the general cians and to countries with more than 100 physicians in the ward for continued care. 5. Perform a tracheostomy and transfer the patient to the general database and, at the end of 2003, invited physicians on this list ward, but with the intent to stop enteral feeding. to reply to a simple questionnaire sent by e-mail. Two remind- ers were sent to those who did not reply to the first e-mail. Question 4. While the possible options are being considered, let us The questionnaire consisted of a case scenario and 4 ques- imagine that the patient rapidly develops fever and septic shock, presumably due to lung infection. What would likely be done in your tions with 3 to 5 optional answers (Table 1). The question- institution? naire was given in English, which is the official language of this 1. Maintain mechanical ventilation and start antibiotics and international symposium. The participants were invited to an- vasopressors. swer by e-mail, and it was guaranteed that they would be anony- 2. Maintain mechanical ventilation and start antibiotics but no mous in the data analysis. We excluded answers received from vasopressors. nonphysicians from the analysis. European countries were di- 3. Give morphine and reduce ventilatory conditions (“terminal vided into 3 groups by geographic region: Northern Europe weaning”). (Denmark, Finland, the Netherlands, Sweden, and the United 4. Extubate and then give morphine (“terminal extubation”). Kingdom), Central Europe (Austria, Belgium, the Czech Re- public, France, Germany, and Switzerland), and Southern Eu- rope (Greece, Italy, Portugal, and Spain). are consistent with their associations in the table. The goal is STATISTICAL ANALYSIS to obtain a global view of the data that is useful for interpre- tation. The overall ␹2 of the contingency table reflects the de- Statistical analyses were performed using commercial soft- gree of departure from a purely random distribution between ware StatView 5.0 for Windows (SAS Institute Inc, Cary, NC). the responses and the countries. If no relationship exists be- A ␹2 test was used to compare groups. Multivariate statistical tween the countries and the responses, the ␹2 will equal zero.