Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units

Abstract

BackgroundIn France, decisions to limit treatment fall under the Leonetti law adopted in 2005. Leading figures from the French world of politics, science, and justice recently claimed for amendments to the law, considering it incomplete. This study, conducted before any legislative change, aimed to investigate the procedural aspects of withholding/withdrawing treatment in French ICUs and their adequacy with the existing law.MethodsThe characteristics of patients qualified for a withholding/withdrawal procedure were prospectively collected in 43 French ICUs. The study period (60 or 90 days under normal operating conditions) took place in the first half of 2013.ResultsDuring the study period, 777 (14 %) of 5589 admitted patients and 584 (52 %) of 1132 patients dying in the ICU had their treatment withheld or withdrawn. Whereas 344 patients had treatment(s) withheld (i.e., not started or not increased if already engaged), 433 had one or more treatment(s) withdrawn. Withdrawal of treatment was applied in 156 of 223 (70 %) brain-injured patients, compared to 277 of 554 (50 %) patients with other reasons for admission (p < 0.01). At the time of the decision-making, the patient’s wishes were known in 181 (23 %) of the 777 cases in one or more different way(s): 73 (9.4 %) from the patient, 10 (1.3 %) by advance directives, 10 (1.3 %) through a designated trusted person, and 108 (13.9 %) reported by the family or close relatives. An external consultant was involved in less than half of all decisions (356 of 777, 46 %). Of the 777 patients qualified for a withholding/withdrawal procedure, 133 (17 %) were discharged alive from the hospital (126 after withholding, 7 after withdrawal).ConclusionsMore than half of deaths in the study population occurred after a decision to withhold or withdraw treatment. Among patients under withholding/withdrawal procedures, brain-injured subjects were more likely to undergo a withdrawal procedure. The prevalence of advance directives and designated trusted persons was low. Because patients’ preferences were unknown in more than three quarters of cases, decisions remained primarily based on medical judgment. Limitations, especially withholding of treatment, did not preclude survival and hospital discharge.

The status of intensive care medicine research and a future agenda for very old patients in the ICU

“…Data from the North American SUP-PORT and European Ethicus studies also documented that information about a patient's wishes regarding EOL decisions was available in only 20% of competent patients [38,39]. This was, again, confirmed in more recent studies [40,41], in which only 57% of families were involved in providing information related to EOL decisions in VOPs. A recent Asian study of elderly (mean greater than 80 years old) patients in ICU similarly reported that pre-acute event advance directives were documented in less than 3% of reviewed cases in ICU [42].…”

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). This study was conducted before the Maastricht III program was launched in France, under conditions enabling a state-of-play of practices without the physicians responsible for WhWd decisions being pressured by any © Annals of Translational Medicine.…”

“…Brain-injured patients are rarely or never conscious at the time of the decision-making and cannot be involved in the discussions. In the survey mentioned above, the low level of patients being directly or indirectly involved in the decision-making (23%) may reflect that many were unable to express their preferences once hospitalized, and/or that they did not anticipate such conditions of being before admission (53). While the French law authorizing such practices was passed in 2005, the prevalence of advance directives and designated surrogate persons remains low (53).…”

“…In the survey mentioned above, the low level of patients being directly or indirectly involved in the decision-making (23%) may reflect that many were unable to express their preferences once hospitalized, and/or that they did not anticipate such conditions of being before admission (53). While the French law authorizing such practices was passed in 2005, the prevalence of advance directives and designated surrogate persons remains low (53). When patients in the ICU lack decision-making capacity, WhWd discussions are often shared between physicians, nurses, and family members or relatives acting as surrogates and representing the patient's values and preferences (67,68).…”

The Baby Boom and later life: is critical care fit for the future?

“…Despite the widespread belief that shared decision-making is firmly embedded in clinical practice, a recent French study reported that only 13% of elderly competent ICU patients had been asked about their treatment preferences [30]. Studies from both North America and Europe also documented that information about a patient's wishes regarding EOL decisions was available in only 20% of competent patients [31,32].…”