Limiting intensive care therapy in dying critically Ill patients: Experience from a tertiary care center in United Arab Emirates

Abstract

Background:Limitations of life-support interventions, by either withholding or withdrawing support, are integrated parts of intensive care unit (ICU) activities and are ethically acceptable. The end-of-life legal aspects and practices in United Arab Emirates ICUs are rarely mentioned in the medical literature. The objective of this study was to examine the current practice of limiting futile life-sustaining therapies in our ICU, modalities for implementing of these decisions, and documentations in dying critically ill patients.Materials and Methods:This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected.Methods:This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected.Results:The electronic medical records of 67 patients were reviewed. The commonest method of limiting therapy was no escalation 53.6%. Interventions were withheld in 41.5%. “Do not resuscitate” order was documented in only 16.3%. The commonest method of documenting limitation of therapy was discussion with the family and documenting the prognosis and futility of additional therapy (73.3%). Patients who died early (<48 hrs) compared to patients who died late (>48 hrs) of ICU admission received terminal cardiopulmonary resuscitation more frequently (P < 0.007), had less frequent prognosis documentation (P < 0.009), and had more vasopressors administered (P < 0.006).Conclusion:Withholding therapy after discussion with the family was the preferred mode of limiting therapy in a dying patient.

Provision of renal care for patients with end stage kidney disease in persistent vegetative state, in United Arab Emirates: a national survey of renal physicians

“…In UAE, as in other Arab Gulf countries, health-related decisions are shared family affair and the family members are the provider of the social and spiritual supportive care for the sick family member [27,28]. As such the family members are the primary decision makers for their very sick patients [19,29].…”

“…It was reported elsewhere that physicians in UAE as well as in other countries have more comfort with withholding than with withdrawal of a life-supporting treatment in terminally ill patients [28,32,33]. This could be also related to the difficulty in initiating discussions of withdrawal decisions, lack of hospital policies, and the fear of inducing premature death [18,22].…”

“…ESKD patients have multiple comorbidities and low survival rate, thus advance care planning would facilitate physicians’ decisions in provision of end-of-life renal care [6]. Advance care planning services are not available officially and it is culturally challenging to integrate the concept of advanced care planning in the clinical practice in UAE [28]. In addition, more involvement of other important health-care providers, nurses, and social workers in shared clinical decision process along with multiple conversations with the family members, would facilitate incorporation of conservative CKD care, and educate the patients’ family regarding the best appropriate medical care for their sick family member [11,34].…”