Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions

Phua, Jason; Joynt, Gavin M.; Nishimura, Masaji; Deng, Yiyun; Myatra, Sheila Nainan; Chan, Yiong Huak; Binh, Nguyen Gia; Tan, Cheng Cheng; Faruq, Mohammad Omar; Arabi, Yaseen M.; Wahjuprajitno, Bambang; Liu, Shih-Feng; Hashemian, Seyed Mohammad Reza; Kashif, Waqar; Staworn, Dusit; Palo, Jose Emmanuel; Koh, Younsuck; Investigators, Acme Study

doi:10.1007/s00134-016-4347-y

Cited by 59 publications

(58 citation statements)

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“…Even among countries/regions with a high proportion of Chinese populations (e.g. China, Taiwan, Hong Kong, Singapore), Phua et al 's study [3] shows that different education in and access to palliative care were associated with varying attitudes towards withholding and withdrawing life-sustaining interventions.Indeed, different attitudes regarding end-of-life interventions may also exist within one country. In Taiwan, which passed the Hospice and Palliative Care Act in 2000 and Patient Self-Determination Act in 2015, the rate of do-not-resuscitate (DNR) practice in terminally ill patients gradually increased in the last 10 years (2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011) [8] as more education and guidelines became available.…”

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“…enteral nutrition, intravenous fluid therapy, oral suctioning). These physicians, who are more inclined to accede to families' requests to withdraw life-sustaining treatments on financial grounds, are nevertheless more agreeable to follow families' demands to continue these interventions, possibly out of their perceived legal risks associated with a lack of policies and ethical guidance on limiting and overriding family requests for non-beneficial treatments [3].The interesting, albeit somewhat counterintuitive, finding of physicians' relative comfort in foregoing less invasive interventions while continuing aggressive artificial life support in a family-driven environment begs the question of how well families understand these different interventions, and how information regarding these interventions is being communicated. While death in the ICU is common, less than half of the ICU physicians in the study [3]-40.6 % of those from high income countries and 46.3 % from low-middle income countries-feel comfortable in having end-of-life discussions with patients' families.…”

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“…In a large-scale study on the practices of ICU physicians in Asia who manage critically ill patients [2], respondents reportedly often withheld but seldom withdrew life-sustaining treatments at the end-of-life, although variations in attitudes and practice exist across countries and regions. Using the data from that study, Phua et al [3] report in a recent article how regional economic status in particular has a significant impact on ICU physicians' attitudes regarding withholding or withdrawing life-sustaining interventions for end-of-life patients. Physicians in low-middle income countries were less likely to withhold and withdraw resource-intensive and invasive interventions (e.g.…”

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Making good death more accessible: end-of-life care in the intensive care unit

Tsai

2016

Intensive Care Med

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Despite advances in critical care medicine, decisions and communications about withholding or withdrawing lifesustaining interventions are routine for intensive care unit (ICU) physicians who attend critically ill patients [1]. Nonetheless, the quality of the dying process and ICU physicians' comfort in discussing end-of-life issues with families vary not only across the globe but also within a region. In a large-scale study on the practices of ICU physicians in Asia who manage critically ill patients [2], respondents reportedly often withheld but seldom withdrew life-sustaining treatments at the end-of-life, although variations in attitudes and practice exist across countries and regions. Using the data from that study, Phua et al. [3] report in a recent article how regional economic status in particular has a significant impact on ICU physicians' attitudes regarding withholding or withdrawing life-sustaining interventions for end-of-life patients. Physicians in low-middle income countries were less likely to withhold and withdraw resource-intensive and invasive interventions (e.g. cardiopulmonary resuscitation, mechanical ventilation and vasopressors and inotropes, tracheostomy and haemodialysis), although they were more likely to forego less aggressive interventions (e.g. enteral nutrition, intravenous fluid therapy, oral suctioning). These physicians, who are more inclined to accede to families' requests to withdraw life-sustaining treatments on financial grounds, are nevertheless more agreeable to follow families' demands to continue these interventions, possibly out of their perceived legal risks associated with a lack of policies and ethical guidance on limiting and overriding family requests for non-beneficial treatments [3].The interesting, albeit somewhat counterintuitive, finding of physicians' relative comfort in foregoing less invasive interventions while continuing aggressive artificial life support in a family-driven environment begs the question of how well families understand these different interventions, and how information regarding these interventions is being communicated. While death in the ICU is common, less than half of the ICU physicians in the study [3]-40.6 % of those from high income countries and 46.3 % from low-middle income countries-feel comfortable in having end-of-life discussions with patients' families. Such discomfort highlights the possibility that even well-intended clinicians may miss valuable opportunities to address and clarify families' misunderstandings and concerns regarding goals of care at the end of life [4].While Phua et al. 's [3] regional focus may invite EastWest comparisons on cultural attitudes and decisionmaking processes regarding death and dying [5], culture is only meaningful when analysed and interpreted in particular local sites and contexts [6]. Socio-economic, legal, professional, religious, educational and technological factors intersect and frame not only families' expectations but also clinicians' contribution and responses to these expectation...

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Making good death more accessible: end-of-life care in the intensive care unit

Tsai

2016

Intensive Care Med

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Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

Sprung

Ricou

Hartog

et al. 2019

JAMA

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161

104

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IMPORTANCE End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time.OBJECTIVE To determine the changes in end-of-life practices in European ICUs after 16 years. DESIGN, SETTING, AND PARTICIPANTS Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999)(2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision.

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Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications

Brodie

Slutsky

Combes

2019

JAMA

262

252

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t is estimated that nearly 2 million people with acute respiratory failure are hospitalized annually in the United States at a cost exceeding $50 billion. 1 Approximately half require invasive mechanical ventilation, and in-hospital mortality exceeds 20% in these patients. 1 Mechanical ventilation has been the primary management tool for patients with acute respiratory failure since the 1950s' polio epidemic, yet it is associated with major complications that can increase mortality. 2 Consequently, there is a need for better ventilatory strategies, as well as alternative modes of respiratory support. In this setting, extracorporeal life support (ECLS), which provides gas exchange via an extracorporeal circuit, is increasingly being used to provide support to failing lungs, a failing heart, or both (Figure 1).Rudimentary versions of ECLS developed in the 1970s were used for several decades but were largely abandoned because they lacked compelling evidence for their efficacy and resulted in major complications. 3,4 However, improvements in technology renewed interest in ECLS. 5 Over the last decade, use of ECLS has substantially increased (eFigure, A in the Supplement), at times, far outpacing the evidence justifying its use. [5][6][7] An increasing evidence base now supports greater use of ECLS for adult patients in respiratory failure. [8][9][10][11] This review examines the reemergence of ECLS, discussing the physiologic rationale, current evidence, indications, and complications associated with its use in adult patients with respiratory failure and other related conditions. Importantly, ethical IMPORTANCE The substantial growth over the last decade in the use of extracorporeal life support for adults with acute respiratory failure reveals an enthusiasm for the technology not always consistent with the evidence. However, recent high-quality data, primarily in patients with acute respiratory distress syndrome, have made extracorporeal life support more widely accepted in clinical practice.OBSERVATIONS Clinical trials of extracorporeal life support for acute respiratory failure in adults in the 1970s and 1990s failed to demonstrate benefit, reducing use of the intervention for decades and relegating it to a small number of centers. Nonetheless, technological improvements in extracorporeal support made it safer to use. Interest in extracorporeal life support increased with the confluence of 2 events in 2009:(1) the publication of a randomized clinical trial of extracorporeal life support for acute respiratory failure and (2) the use of extracorporeal life support in patients with severe acute respiratory distress syndrome during the influenza A(H1N1) pandemic. In 2018, a randomized clinical trial in patients with very severe acute respiratory distress syndrome demonstrated a seemingly large decrease in mortality from 46% to 35%, but this difference was not statistically significant. However, a Bayesian post hoc analysis of this trial and a subsequent meta-analysis together suggested that extracorporeal life suppo...

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Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions

Abstract: Significant differences in ICU physicians' self-reported practice of limiting life-sustaining treatments, the role of families and surrogates, perception of legal risks and financial considerations exist between low-middle-income and high-income Asian countries and regions.

Cited by 59 publications

References 33 publications

Making good death more accessible: end-of-life care in the intensive care unit

Making good death more accessible: end-of-life care in the intensive care unit

Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications

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