ICU Triage/Quality of LifeLimiting life-sustaining treatment in German intensive care units: A multiprofessional survey☆
Introduction
One of the most frequent ethical problems faced by clinical medicine is end-of-life decision making, particularly in the context of intensive care medicine [1]. It has been established for a number of countries that 50% to 90% of deaths in intensive care units (ICUs) are associated with withholding or withdrawing life-sustaining treatment (LST), corresponding to 6% to 11% of all patients admitted to ICUs [2], [3]. End-of-life decisions are a complex social phenomenon. In multiprofessional environments such as an ICU, various professions with different professional ethics, attitudes, and experiences have to come to a shared decision. Intercultural aspects and the organizational hierarchy of authority and accountability contribute to complexity [4], [5], [6]. However, most empiric studies so far did not investigate these different levels of hierarchy and compare, for example, the perspectives of junior and senior health care professionals.
We therefore aimed to study the different perspectives of intensive care physicians and nurses on end-of-life decision making, both on senior and junior levels. We were interested in their experiences regarding (1) the perceived frequency of limiting LST (=withdrawing or withholding LST) and (2) the specific forms of treatment limited, (3) level of uncertainty and distress when confronted with end-of-life decisions, (4) the quality of the communication process and outcome, and (5) the practice of documentation.
We focused on the situation in Germany. End-of-life decision making is increasingly being discussed in Germany, both publicly and professionally [7]. However, there are only 2 published empirical studies on the practice of end-of-life decision making in German speaking ICUs and the perspectives of intensive care clinicians. In 1998, a pilot survey among a small sample of ICU physicians in Innsbruck, Austria, indicated that there is much uncertainty, and withholding is given priority over withdrawing [8]. In a survey among members of the European Society of Intensive Care Medicine done in 1999, German intensivists reported admitting even patients with a dismal prognosis on the ICU and favoring withholding over withdrawing treatment [9].
Hierarchical hospital structures and a special relationship between the academically trained physicians and the nonacademically trained nurses who traditionally focus more on basic body care than medical treatment are hallmarks that make Germany an interesting field of study for these research questions. Our hypothesis was that based on this professional culture, German nurses and physicians show substantial heterogeneity in end-of-life decision making and perceive major problems in end-of-life communication.
Section snippets
Sample
All physicians and nurses working in 1 of the 10 adult ICUs of the University Hospital of Munich, Germany, were invited to participate in the study. The survey was part of a longitudinal evaluation study of a hospital ethics policy. Physicians included attending physicians, residents, and interns. The nursing staff comprised all examined nurses, with or without a special qualification in intensive care nursing.
Survey instrument
Each participant was asked to complete a 25-item questionnaire written in German. To
Results
The questionnaire was sent to 363 health care professionals—268 nurses and 95 physicians. From the returned 204 questionnaires, 7 were not analyzable due to missing demographic data. Among the 197 analyzed questionnaires (53%), 149 came from nurses (response rate, 56%) and 48 from physicians (response rate, 51%). Two thirds of the respondents were women (n = 130, 66%; male: n = 67, 34%), and three quarters were nurses (n = 149, 76%; physicians: n = 48, 24%). Regarding the professional position,
Discussion
The survey had a response rate of above 50%, which is in the expected range for a survey among health care professionals [10]. The data show that German intensive care clinicians are frequently confronted with the question of limiting LST. The median frequency reported by junior physicians is once a week. According to the local hospital statistics, the approximate number of admissions to an ICU is 10 per week. This implies that every 10th patient poses the need to decide on limiting LST. This
Conclusions
This study is the first to provide empirical data on the limitation of LST in German ICUs. The survey of ICU physicians and nurses indicates a high prevalence of limiting LST, except for limiting artificial nutrition, hydration, and mechanical ventilation. Despite the high prevalence, there are major deficits in team communication, documentation practices, and the involvement of the patient's family. Professional training and continuing education should intensify efforts in teaching
Acknowledgments
The authors are grateful for the support of the medical and nursing boards of the Munich University Hospital and the active collaboration of multiple head nurses and attending physicians in the ICUs. Special thanks are due to Birgit Müller and Peter Jacobs from the nursing management for advisory help. The authors are also grateful for creative ideas and critical appraisal of the study by all members of the research working group at the Interdisciplinary Center for Palliative Medicine, Munich.
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The work of R.J.J. was supported by a fellowship of the Bavarian Research Foundation, Munich, Germany (PIZ 74/05).