International differences in end-of-life issues in the ICU

Medicine is in a state of continual progression as new therapies and interventions are developed and technological advances facilitate resuscitation and prolonged organ support. In addition, patients are living longer with increased numbers of comorbidities and complex disease processes. As one result of these demographic changes and medical advances, intensive care units (ICUs) are admitting more patients with a high risk of death, patients who would previously have died before reaching the ICU. As a consequence, the need for end-of-life decisions has become more common than in the past. There has also been a move from an emphasis on survival at all costs to a recognition that the quality of life of survivors must also be taken into account, as well as the quality of dying for those who will not survive.

by Prof Jean-Louis Vincent

With patients who are not considered to have any reasonable chance of benefiting from new or continued intensive care treatments, physicians are faced with four possible options, ranging from continuing with full treatment to support life through to increasing the doses of sedatives to hasten the dying process (Table). In some patients, where withdrawing therapy is permitted, an ICU trial’ can be considered, giving the patient the chance to benefit from a possible intervention. The target of such a test and the time-limit must be set in advance and adhered to; good communication with the family is essential to ensure that these factors are clear. It should be remembered that in some patients, death is actually in their best interest, preventing unnecessary and prolonged suffering.

Recent data suggest that some 40% of ICU non-survivors will have a decision to withhold/withdraw life-sustaining therapy during their ICU stay. Perhaps not surprisingly, there are marked differences in end-of-life decisions and the decision-making practice around the globe. For example, data show that patients are more likely to receive a decision to withhold or withdraw life-sustaining therapy in Oceania, North America, and northern Europe and less commonly in the Middle East, Asia, southern Europe and South America. Although withdrawing and withholding are seen as ethically equivalent in many countries, in others, withholding life-sustaining therapy is considered acceptable but not withdrawing. In Israel, because withdrawal of life-support measures is forbidden, the authorities even passed a law whereby timers can be put on respirators, which then stop by themselves after a preprogrammed time period. The use of sedatives/analgesia at the end-of-life to shorten the dying process also varies considerably among countries and individuals. Some people justify the administration of large doses of sedatives/analgesics in this situation by calling on the double effect’ principle, wherein giving analgesic agents for comfort has the unavoidable effect of hastening death, but this view is rather hypocritical. There is little official guidance available for intensivists regarding this issue and it is perhaps the area of end-of-life management that creates the greatest concern among physicians with fear of possible litigation. The Belgian Society of Intensive Care recently published a statement that ‘Shortening the dying process with use of medication, such as analgesics/sedatives, may sometimes be appropriate, even in the absence of discomfort, and can actually improve the quality of dying’.

The degree of involvement of family members in end-of-life decision making also varies, with families more frequently involved in Northern Europe and the US than in southern European countries. This is in part related to the traditional paternal approach to medical practice still widespread in many southern European countries. Family-centered decision making is also common in East Asian countries, such as Japan, China and South Korea.

The reasons for these international differences are complex. Many are related to the marked cultural and religious diversity among countries. Lack of available resources and financial constraints can also influence end-of-life decision making, particularly in lower income countries. There are also differences among ICUs within a country and among individual intensivists, related again to the cultural and religious backgrounds of the physicians, but also to local legislation, peer and family pressure, and ICU casemix and organization amongst others. The key ethical principles of autonomy, beneficence, non-maleficence and distributive justice must always be used as the basis for any end-of-life decision, but the ways in which these are interpreted and their relative importance may vary according to local factors. It is therefore inappropriate to try and develop a universal consensus on end-of-life decisions as some have suggested, although local guidelines may be useful. Open discussion of these difficult issues must be encouraged within the ICU team and good communication with the family is essential. The aim must always be to provide compassionate end-of-life care, appropriate for the individual patient and his/her particular circumstances.

Suggested reading
Curtis JR and Vincent JL Ethics and end-of-life care for adults in the intensive care unit. Lancet 2010;376:1347-53.
Myburgh J, et al End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 2016; 34:125-30
Vincent JL, et al ‘Piece’ of mind: end of life in the intensive care unit statement of the Belgian Society of Intensive Care Medicine. J Crit Care 2014;29:174-175

The author
Jean-Louis Vincent, MD, PhD
Dept of Intensive Care,
Erasme University Hospital,
Universite libre de Bruxelles,
Route de Lennik 808,
1070 Brussels,
Tel. +32-2-555-3380
Fax +32-2-555-4555