Policies of withholding and withdrawal of life-sustaining treatment in critically ill patients on cardiac intensive care units in Germany: a national survey
Gydimo nutraukimo politika sunkiai serganciu pacientu, Vokietijos kardio terapijos skyriouse: nacionalinės apklausa

Išskaičiavimo politika ir gyvybei palaikyti gydymo panaikinimas sunkiai sergantiems pacientams, intensyvios širdies terapijos skyriuose Vokietijoje: nacionalinės apklausos
Abstract
OBJECTIVE
To determine the decision-making process of withholding and/or withdrawal (WH/WD) of life-sustaining treatment in cardiac intensive care units (ICUs) in Germany.
METHODS
A questionnaire regarding 16 medical and 6 ethical questions of WH/WD of life-sustaining treatment was distributed to the clinical director, senior ICU physician and head nurses of all German heart surgery centres (n = 237 questionnaires). Furthermore, we present a literature survey using the key words ‘End-of-life care AND withholding/withdrawal of life support therapy AND intensive care unit’.

TIKSLAS
Norėdami nustatyti sprendimų priėmimo procesą išskaičiavimas ir / ar panaikinimą (WH / WD ) gyvenimą išlaikyti gydymo širdies intensyvios terapijos skyriuose ( ICUs ) Vokietijoje.
METODAI
Klausimynas apie 16 medicinos ir 6 etinius klausimus WH / WD gyvenimą išlaikyti gydymo buvo išplatintas klinikinės direktoriaus, vyresniųjų ITS gydytojas ir galvos slaugytojų visų Vokietijos širdies chirurgijos centrų (n = 237 anketų ). Be to, mes pristatome literatūros apklausą naudojantraktažodžiai Eksploatuoti netinkamos priežiūros ir išskaičiuojamąjį / pasitraukimo iš gyvybės palaikymo gydymo ir intensyvios terapijos skyriuje . "
RESULTS
We received replies from 86 of 237 (36.3%) contacted persons. Concerning medical reasons, cranial computed tomography (CCT) with poor prognosis (91.9%), multi-organ failure (70.9%) and failure of assist device therapy (69.8%) were the three most frequently cited medical reasons for WH/WD life-sustaining treatment. Overall, 32.6% of persons answered that ethical aspects influence their decision-making processes. Poor expected quality of life (48.8%), the patient's willingness to limit medical care (40.7%) and the families’ choice (27.9%) were the top three reported ethical reasons. There was a significant difference regarding the perception of the three involved professional groups concerning the decision-making parameters: multi-organ failure (P = 0.018), failure of assist device therapy (P = 0.001), cardiac index (P = 0.009), poor expected quality of life (P = 0.009), the patient's willingness to limit medical care (P = 0.002), intraoperative course (P = 0.054), opinion of family members (P = 0.032) and whether decision-making process are done collaboratively (clinical director, 45.7%; ICU physician, 52%; and head of nursing staff, 26.9%). Palliation medication in patients after WH/WD of life-support consisted of morphine (92%) and benzodiazepines (88%).
CONCLUSIONS
This survey is a step towards creating standards of end-of-life care in cardiac ICUs, which may contribute to build consensus and avoid conflicts among caregivers, patients and families at each step of the decision-making process.
Keywords: Withholding/withdrawal of life support therapy, Heart surgery intensive care unit, National survey
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INTRODUCTION
Because of the strict focus of intensive care medicine on a curative intention, physicians may experience difficulties in changing the intention to treat towards a model focusing primarily on symptomatology. Patients with a poor prognosis or an expectancy of permanently reduced quality-of-life may not benefit from curatively intended intensive care, but may cause high expenses [1]. However, making an objective decision towards cessation of life support remains a serious issue. Attempts have been made to define the ‘doomed’ patient [2, 3] and the circumstances resulting in ‘futile’ curatively intended care [4]. On the contrary, the ultimate