Pattern of end-of-life decisions in two Tunisian intensive care units: the role of culture and intensivists’ training

Ouanes, Islem; Stambouli, Néji; Dachraoui, Fahmi; Ouanes-Besbes, Lamia; Toumi, Samir; Salem, Faouzi Ben; Gahbiche, M.; Abroug, Fékri

doi:10.1007/s00134-012-2500-9

Cited by 12 publications

(5 citation statements)

References 39 publications

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“…Some studies suggest that this variation originates from institutional factors [10,[16][17][18][19][20][21], physician factors [10,[22][23][24][25], and religion/geographic factors [25][26][27]. Variation in earlier studies was not only found between countries, but also within countries [10,[16][17][18][28][29][30][31][32][33][34], and even within the same department [23]. This could indicate that cultural or regional differences are not the sole trigger of variation in the occurrence of WLSM.…”

Section: Discussionmentioning

confidence: 96%

Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study

et al. 2021

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Background: In patients with severe brain injury, withdrawal of life-sustaining measures (WLSM) is common in intensive care units (ICU). WLSM constitutes a dilemma: instituting WLSM too early could result in death despite the possibility of an acceptable functional outcome, whereas delaying WLSM could unnecessarily burden patients, families, clinicians, and hospital resources. We aimed to describe the occurrence and timing of WLSM, and factors associated with timing of WLSM in European ICUs in patients with traumatic brain injury (TBI). Methods:The CENTER-TBI Study is a prospective multi-center cohort study. For the current study, patients with traumatic brain injury (TBI) admitted to the ICU and aged 16 or older were included. Occurrence and timing of WLSM were documented. For the analyses, we dichotomized timing of WLSM in early (< 72 h after injury) versus later (≥ 72 h after injury) based on recent guideline recommendations. We assessed factors associated with initiating WLSM early versus later, including geographic region, center, patient, injury, and treatment characteristics with univariable and multivariable (mixed effects) logistic regression.Results: A total of 2022 patients aged 16 or older were admitted to the ICU. ICU mortality was 13% (n = 267). Of these, 229 (86%) patients died after WLSM, and were included in the analyses. The occurrence of WLSM varied between regions ranging from 0% in Eastern Europe to 96% in Northern Europe. In 51% of the patients, WLSM was early. Patients in the early WLSM group had a lower maximum therapy intensity level (TIL) score than patients in the later WLSM group (median of 5 versus 10) The strongest independent variables associated with early WLSM were one unreactive pupil (odds ratio (OR) 4.0, 95% confidence interval (CI) 1.3-12.4) or two unreactive pupils (OR 5.8, CI 2.6-13.1) compared to two reactive pupils, and an Injury Severity Score (ISS) if over 41 (OR per point above 41 = 1.1, CI 1.0-1.1). Timing of WLSM was not significantly associated with region or center. Conclusion:WLSM occurs early in half of the patients, mostly in patients with severe TBI affecting brainstem reflexes who were severely injured. We found no regional or center influences in timing of WLSM. Whether WLSM is always appropriate or may contribute to a self-fulfilling prophecy requires further research and argues for reluctance to institute WLSM early in case of any doubt on prognosis.

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Section: Discussionmentioning

confidence: 96%

Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study

et al. 2021

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“…When compared with patients with other chronic diseases, cancer patients usually have to experience much more psychological stress and economic burden in addition to physical sufferings. It was reported that critically ill patients with malignancy or ultimately fatal underlying diseases were more likely to have their life-sustaining therapy withheld or withdrawn than those without malignancy or fatal diseases [15]–[16]. A study of a specialized cancer center in Jordan demonstrated a high proportion (48.6%) of adult cancer patients making decisions to withhold or withdraw life support measures [17], which was even higher than the result of our center.…”

Section: Discussionmentioning

confidence: 59%

Current Situation and Associated Factors of Withdrawing or Withholding Life Support to Patients in an Intensive Care Unit of Cancer Center in China

et al. 2014

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ObjectivesTo investigate the current situation and analyze the associated factors of withdrawing or withholding life support in the intensive care unit (ICU) of our cancer center.MethodsThree hundred and twenty-two cancer patients in critical status were admitted to our ICU in 2010 and 2011. They were included in the study and were classified into two groups: withdrawing or withholding life support (WWLS), and full life support (FLS). Demographic information and clinical data were collected and compared between the two groups. Factors associated with withdrawing or withholding life support were analyzed with univariate and multivariate logistic regression analysis.ResultsEighty-two of the 322 cases (25.5% of all) made the decisions to withdraw or withhold life support. Emergency or critical condition at hospital admission, higher scores of Acute Physiology and Chronic Health Evaluation II (APACHE II) in 12 hours after ICU admission, financial difficulties and humanistic care requirements are important factors associated with withdrawing or withholding life support.ConclusionsWithdrawing or withholding life support is not uncommon in critically ill cancer patients in China. Characteristics and associated factors of the decision-making are related to the current medical system, medical resources and traditional culture of the country.

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“…Indian nurses felt it correct to continue hydration and feeding until death, but not to initiate invasive procedures [35], with a high threshold for treatment initiation has been found [36]. Such findings are mirrored in studies in other countries such as Egypt and Tunisia [31,37], and a study in Pakistan found that 16% would not withdraw life support under any circumstances [29].…”

Section: Withholding Withdrawing Treatment Futility and Legal Issuesmentioning

confidence: 99%

Palliative and end-of-life care in intensive care units in low- and middle-income countries: A systematically constructed scoping review

Rao¹,

Salins

Joshi³

et al. 2022

Journal of Critical Care

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Pattern of end-of-life decisions in two Tunisian intensive care units: the role of culture and intensivists’ training

Abstract: Withholding and withdrawing life support are common in medical and surgical ICUs of a Tunisian hospital. Withholding is more frequent than withdrawing life support. These decisions appear to be effected by functional status and underlying conditions.

Cited by 12 publications

References 39 publications

Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study

Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study

Current Situation and Associated Factors of Withdrawing or Withholding Life Support to Patients in an Intensive Care Unit of Cancer Center in China

Palliative and end-of-life care in intensive care units in low- and middle-income countries: A systematically constructed scoping review

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