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Background: Decisions of patients, families, and health care providers about medical care at the end of life depend on many factors, including the societal culture. A pan-European study was conducted to determine the frequency and types of end of life practices in European intensive care units (ICUs), including those in Israel. Several results of the Israeli subsample were different to those of the overall sample. Objective: The objective of this article was to explore these differences and provide a possible explanation based on the impact of culture on end of life decision making. Method: All adult patients admitted consecutively to three Israeli ICUs (n = 2778) who died or underwent any limitation of life saving interventions between 1 January 1999 and 30 June 2000 were studied prospectively (n = 363). These patients were compared with a similar sample taken from the larger study (ethics in European intensive care units: ETHICUS) carried out in 37 European ICUs. Patients were followed until discharge, death, or 2 months from the decision to limit therapy. End of life decisions were prospectively organised into one of five mutually exclusive categories: cardiopulmonary resuscitation (CPR), brain death, withholding treatment, withdrawing treatment, and active shortening of the dying process (SDP). The data also included patient characteristics (gender, age, ICU admission diagnosis, chronic disorders, date of hospital admission, date and time of decision to limit therapy, date of hospital discharge, date and time of death in hospital), specific therapies limited, and the method of SDP. Results: The majority of patients (n = 252, 69%) had treatment withheld, none underwent SDP, 62 received CPR (17%), 31 had brain death (9%), and 18 underwent withdrawal of treatment (5%). The primary reason given for limiting treatment was that the patient was unresponsive to therapy (n = 187). End of life discussions were held with 132 families (36%), the vast majority of which revolved around withholding treatment (91% of the discussions) and the remainder concerned withdrawing treatment (n = 11, 9%). There was a statistically significant association (x 2 = 830.93, df = 12, p , 0.0001) between the type of end of life decision and region-that is, the northern region of Europe, the central region, the southern region, and Israel. Conclusions: Regional culture plays an important part in end of life decision making. Differences relating to end of life decision making exist between regions and these differences can often be attributed to cultural factors. Such cultures not only affect patients and their families but also the health care workers who make and carry out such decisions.
Background The number of Australians dying each year is predicted to double in the next 25 years and there is an urgent need to establish sustainable models for providing high quality end‐of‐life care. An innovative community care model (Bupa Palliative Care Choices Program or BPCCP) was developed and piloted with the purpose of supporting patients in achieving their choices surrounding end‐of‐life care. Aims This study evaluates whether BPCCP patients were more likely to die in their place of choice compared with patients receiving standard care. Additional aims were evaluating patient and carer satisfaction and insurer cost. Methods This prospective, comparative cohort study comprises a clinical chart audit and survey of patient and carer experience. Results More BPCCP participants preferred to die at home (53% vs 31%). A lower proportion of BPCCP patients died in acute hospitals (10% vs 19%) and more of this cohort died at home (46% vs 26%). In both cohorts, nearly 90% of patients were able to die in their preferred location. Patient and carer satisfaction with the programme was very high in the small cohort who responded to the survey. There was a decrease in average claims spend per patient enrolled in the programme during the first 12‐month period of implementation compared with historical claims spend for inpatients only. Conclusions This evaluation of an innovative community palliative care intervention indicates that the extra services available to patients support the choice of dying at home and the ability to do so while generating claims cost efficiencies.
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