Withholding and Withdrawal of Life-Sustaining Treatments in Intensive Care Units in Asia

Abstract

for the ACME Study Investigators and the Asian Critical Care Clinical Trials Group IMPORTANCE Little data exist on end-of-life care practices in intensive care units (ICUs) in Asia. OBJECTIVE To describe physicians' attitudes toward withholding and withdrawal of life-sustaining treatments in end-of-life care and to evaluate factors associated with observed attitudes. DESIGN, SETTING, AND PARTICIPANTS Self-administered structured and scenario-based survey conducted among 1465 physicians (response rate, 59.6%) who manage patients in ICUs (May-December 2012) at 466 ICUs (response rate, 59.4%) in 16 Asian countries and regions.RESULTS For patients with no real chance of recovering a meaningful life, 1029 respondents (70.2%) reported almost always or often withholding whereas 303 (20.7%) reported almost always or often withdrawing life-sustaining treatments; 1092 respondents (74.5%) deemed withholding and withdrawal ethically different. The majority of respondents reported that vasopressors, hemodialysis, and antibiotics could usually be withheld or withdrawn in end-of-life care, but not enteral feeding, intravenous fluids, and oral suctioning. For severe hypoxic-ischemic encephalopathy after cardiac arrest, 1201 respondents (82.0% [range between countries, 48.4%-100%]) would implement do-not-resuscitate orders, but 788 (53.8% [range, 6.1%-87.2%]) would maintain mechanical ventilation and start antibiotics and vasopressors if indicated. On multivariable analysis, refusal to implement do-not-resuscitate orders was more likely with physicians who did not value families' or surrogates' requests (adjusted odds ratio [AOR], 1.67 [95% CI, 1.16-2.40]; P = .006), who were uncomfortable discussing end-of-life care (AOR, 2.38 [95% CI, 1.62-3.51]; P < .001), who perceived greater legal risk (AOR, 1.92 [95% CI, 1.26-2.94]; P = .002), and in low-to middle-income economies (AOR, 2.73 [95% CI, 1.56-4.76]; P < .001). Nonimplementation was less likely with physicians of Protestant (AOR, 0.36 [95% CI, 0.16-0.80]; P = .01) and Catholic (AOR, 0.22 [95% CI, 0.09-0.58]; P = .002) faiths, and when out-of-pocket health care expenditure increased (AOR, 0.98 per percentage of total health care expenditure [95% CI, 0.97-0.99]; P = .02). CONCLUSIONS AND RELEVANCEWhereas physicians in ICUs in Asia reported that they often withheld but seldom withdrew life-sustaining treatments at the end of life, attitudes and practice varied widely across countries and regions. Multiple factors related to country or region, including economic, cultural, religious, and legal differences, as well as personal attitudes, were associated with these variations. Initiatives to improve end-of-life care in Asia must begin with a thorough understanding of these factors.

A few realistic questions raised by organ retrieval in the intensive care unit

“…Contrary to ethicists (22,45,46), many intensivists clearly distinguish between "withholding" and "withdrawal" decisions, with the former being perceived as more passive (47)(48)(49)(50)(51)(52). By establishing a three-level hierarchy of decisions ("stop" > "do not increase" > "do not start"), a French epidemiological survey demonstrated that the more "active" limitations (withdrawal of life-sustaining therapy) mostly involved severely braininjured patients (post-anoxic coma, stroke, head trauma), whereas patients with chronic respiratory disease, preexisting disability affecting autonomy or cognition, and/or respiratory failure on admission had treatment preferentially withheld rather than withdrawn (53).…”

Changes in Life-sustaining Treatment in Terminally Ill Cancer Patients after Signing a Do-Not-Resuscitate Order

“…심폐소생술금지에 동의한 말기암환자는 침습적 시술 을 포함하여 위관영양, 투석, 수혈, 항생제 등의 치료 중 단을 선택한 것으로 간주된다 (13). 이처럼 현재 심폐소 생술금지는 임종 환자에게 시행되는 무의미한 치료를 중단하는 하나의 방법으로 제시되고 있다 (14).…”

The Authors Reply

“…However, end-of-life (EOL) care practices are complex and are influenced by multiple factors, including the physicians' personal attitudes, family decisions, economic status, hospital policy, societal culture, and legislation. [2,3] For these reasons, the decision for do-not-resuscitate (DNR) orders and the withholding or withdrawal of life-sustaining management remains both a challenge and an important issue in intensive care units (ICUs).…”

“…Specifically, ICU physicians in Asia tend to allow life-sustaining treatments at the EOL more frequently than physicians in Western countries. [2,7,8] Many Asian physicians also decide to withhold life-sustaining treatments rather than withdraw therapy. [2,7] There have been a few articles about the relationship between the time of DNR designation and mortalities.…”