Date Published: October 1, 2012
Publisher: Public Library of Science
Author(s): Jan A. Graw, Claudia D. Spies, Klaus-D. Wernecke, Jan-Peter Braun, Apar Kishor Ganti. http://doi.org/10.1371/journal.pone.0046446
End-of-life-decisions (EOLD) have become an important part of modern intensive care medicine. With increasing therapeutic possibilities on the one hand and many ICU-patients lacking decision making capacity or an advance directive on the other the decision making process is a major challenge on the intensive care unit (ICU). Currently, data are poor on factors associated with EOLD in Germany. In 2009, a new law on advance directives binding physicians and the patient´s surrogate decision makers was enacted in Germany. So far it is unknown if this law influenced proceedings of EOLD making on the ICU.
A retrospective analysis was conducted on all deceased patients (n = 224) in a 22-bed surgical ICU of a German university medical center from 08/2008 to 09/2010. Patient characteristics were compared between patients with an EOLD and those without an EOLD. Patients with an EOLD admitted before and after change of legislation were compared with respect to frequencies of EOLD performance as well as advance directive rates.
In total, 166 (74.1%) of deaths occurred after an EOLD. Compared to patients without an EOLD, comorbidities, ICU severity scores, and organ replacement technology did not differ significantly. EOLDs were shared within the caregiverteam and with the patient´s surrogate decision makers. After law enacting, no differences in EOLD performance or frequency of advance directives (8.9% vs. 9.9%; p = 0.807) were observed except an increase of documentation efforts associated with EOLDs (18.7% vs. 43.6%; p<0.001). In our ICU EOLD proceedings were performed patient-individually. But EOLDs follow a standard of shared decision making within the caregiverteam and the patient´s surrogate decision makers. Enacting a law on advance directives has not affected the decision making-process in EOLDs nor has it affected population´s advance care planning habits. However, it has led to increased EOLD-associated documentation on the ICU. ClinicalTrials.gov NCT01294189.
Mortality on intensive care units ranges from 6–18% in Europe –. The subsequent introduction of multiple artificial organ support and replacement technology has caused a redefinition of death – shifting it from a sudden and unexpected event to a process . The boundaries between medical therapy prolonging life to this therapy prolonging dying became fluid. Consequently most patients in the intensive care unit (ICU) (60%–80%) die after an end-of-life-decision (EOLD) has been made, a decision to limit full life support –, , .
The Medical Ethics Committee of Charité University Hospital approved this study (number of ethical approval EA1/292/10). The study was registered as a clinical trial (ClinicalTrials.gov Identifier: NCT01294189). Informed consent was waived due to the retrospective and observational nature of the study.
EOLDs were taken within a median ICU length of stay (LOS) of five days for DNRs (interquartile range (IQR): 2–15) as well as for WH/WDLS decisions (IQR: 2–19). After any EOLD patients died within a median of one day (IQR: 0–3). The characteristics of the decedents are presented in Table 1. Furthermore differences in baseline comorbidities, ICU severity scores, ICU-LOS, organ replacement technology and advanced care planning for the different groups are shown in Table 1.
Approximately three quarters of deaths on the ICU (74.1%) were preceded by an EOLD indicating that the process of dying was conscientiously taken into consideration and orchestrated by medical and nursing staff. Decisions on withholding or withdrawing therapeutic approaches were done patient-individually and irrespective of formal criterias.