Withholding and withdrawing life-sustaining treatment: Experiences in limiting futile therapy from three Polish intensive care departments

Abstract

Background. In intensive care units (ICUs), a patient's vital functions may be maintained, regardless of the patient's chances of survival. A key issue is how to precisely determine the moment in which life-support treatment should be withheld. In many countries, the decision-making process is regulated by the guidelines of scientific societies. However, heuristic errors may influence this process. Objectives. The objective of this study was to assess factors involved in decisions to implement or withhold treatment in general ICUs in Poland. Material and methods. The medical records of patients treated in 3 clinical ICUs of general, cardiosurgical and neurosurgical profile were retrospectively analyzed. Patients with a diagnosis of brain death were finally excluded from the study. Results. The records of 1,449 patients hospitalized between January 1, 2014 and December 31, 2014 were analyzed. Of these, 226 patient cases were evaluated. There were no correlations between the placement of restrictions on resuscitation in specific cases, use of noradrenaline, frequency of blood gas testing, and patients' age. There was a relationship between these factors and the duration of hospitalization in the ICU. There was a direct relation between a "do not resuscitate" (DNR) order in a patient's record and the frequency of both resuscitation procedures and withholding catecholamine treatment in the hours preceding a patient's death. Conclusions. Treatment was withheld in about 20% of cases involving dying patients in analyzed ICUs, regardless of age. Placing a limit on treatment consisted of either withholding new procedures or withdrawing existing therapy. The length of stay in the ICU affected the decisions to limit treatment.

End-of-life management in intensive care units: a multicentre observational prospective cohort study

“…In a study about withholding and withdrawal practices for life-sustaining treatments, no association was found between withholding treatment and age. However, the authors of the study found a correlation between withholding treatment and the duration of ICU stay [20].…”

“…Therefore, the need to promote protocols for screening and the effective implementation of ELM-PC in ICU teams is still a necessity, at least in the population and in the region addressed in this study. A significant relationship has been found between the application of a "do not resuscitate" (DNR) order and withholding noradrenaline treatment in the hours preceding the patient's death [20].…”

Public Attitude towards Implementing DNAR and a Stance on Pediatric DNAR in Poland—A Prospective Survey Study

“…Religion, years in practice or institution did not affect their agreement, but religiosity, physician specialty and responsibility for end-of-life decisions did [ 17 ]. Only one recently published study in an intensive care unit described a relation between a DNAR order in a patient’s documentation and the frequency of both resuscitation procedures and withholding catecholamine treatment in the hours preceding a patient’s death [ 18 ]. The complexities of the decision not to perform CPR in pediatric hospital settings were recently described as discrepancies identified between practice and medical records in DNR pediatric patients [ 19 ].…”

Práticas de cuidado hospitalares no final de vida: revisão integrativa

“…Em relação à idade, estudo francês (Nesseler et al, 2018) converge com os achados desta revisão, indicando relação entre idade avançada e limitação de tratamentos mantenedores da vida. Já estudo realizado em UTI's na Polônia encontrou resultados divergentes, não evidenciando relação significativa entre idade e a suspensão de uso de vasopressores (Siewiera et al, 2019). Igualmente, constatou que médicos possuem maior propensão em limitar tratamentos como coleta de gasometria, prescrição de vasopressores ou correção sérica de sódio e potássio, do que retirá-los por completo.…”