Attitudes of European physicians, nurses, patients, and families regarding end-of-life decisions: the ETHICATT study

Objective To evaluate attitudes of Europeans regarding end-of-life decisions. Design and setting Responses to a questionnaire by physicians and nurses working in ICUs, patients who survived ICU, and families of ICU patients in six European countries were compared for attitudes regarding quality and value of life, ICU treatments, active euthanasia, and place of treatment. Measurements and results Questionnaires were distributed to 4,389 individuals and completed by 1,899 (43%). Physicians (88%) and nurses (87%) found quality of life more important and value of life less important in their decisions for themselves than patients (51%) and families (63%). If diagnosed with a terminal illness, health professionals wanted fewer ICU admissions, uses of CPR, and ventilators (21%, 8%, 10%, respectively) than patients and families (58%, 49%, 44%, respectively). More physicians (79%) and nurses (61%) than patients (58%) and families (48%) preferred being home or in a hospice if they had a terminal illness with only a short time to live. Conclusions Quality of life was more important for physicians and nurses than patients and families. More medical professionals want fewer ICU treatments and prefer being home or in a hospice for a terminal illness than patients and families. Electronic supplementary material Supplementary material is available in the online version of this article at and is accessible for authorized users.     

Communication of end-of-life decisions in European intensive care units

Objective To examine end-of-life (EOL) practices in European ICUs: who makes these decisions, how they are made, communication of these decisions and questions on communication between the physicians, nurses, patients and families.Design Data collected prospectively on EOL decisions facilitated by a questionnaire including EOL decision categories, geographical regions, mental competency, information about patient wishes, and discussions with patients, families and health care professionals.Setting 37 European ICUs in 17 countriesPatients ICU physicians collected data on 4,248 patients.Results 95% of patients lacked decision making capacity at the time of EOL decision and patients wishes were known in only 20% of cases. EOL decisions were discussed with the family in 68% of cases. Physicians reported having more information about patients wishes and discussions in the northern countries (31%, 88%) than central (16%, 70%) or southern (13%, 48%) countries. The family was more often told (88%) than asked (38%) about EOL decisions. Physicians reasons for not discussing EOL care with the family included the fact that the patient was unresponsive to therapy (39%), the family was unavailable (28%), and the family was thought not to understand (25%).Conclusions ICU patients typically lack decision-making capacity, and physicians know patients wishes in only 20% of EOL decisions. There were regional differences in discussions of EOL decisions with families and other physicians. In European ICUs there seems to be a need to improve communicationP. Sjokvist died in December 2003Funding was provided by the European Concerted Action project and by the European Commission (contract PL963733), the Chief Scientists Office of the Ministry of Health, Israel (grant no. 4226), the European Society of Intensive Care Medicine (ESICM) and by OFES Switzerland (Biomed, no. 980271)     

End-of-life decisions in intensive care units: attitudes of physicians in an Italian urban setting

Objective To assess the attitudes of physicians in Milan, Italy, intensive care units (ICUs) regarding end-of-life decisions.Design Anonymous self-administered questionnaire.Setting All 20 ICUs in Milan.Participants Physicians employed in the ICUs.Measurements and results The response rate was 87% (225 of 259). Eighty-two percent of respondents estimated that <10% of deaths in their ICU followed foregoing treatment, whereas 6% estimated that more of 25% deaths followed foregoing treatment. Male gender, long professional experience, and activity mainly in the ICU were significantly associated with greater willingness to forego life-sustaining treatments. Eighty-nine percent of respondents said ethical consultation on end-of-life decisions was never sought; 58% said they would not respect the expressed desire of the patient to forego treatment; and 48% never noted the decision to forgo treatment on the clinical record. After a decision to withdraw treatment, 31% of physicians said they maintained ongoing treatment, but withheld CPR for cardiac arrest; 47% considered withholding and withdrawing life support were not ethically equivalent.Conclusions Most physicians considered that most ICU deaths were not the result of deliberately foregoing life support. Although the overall trend was to intervene minimally in patients' dying, individual factors significantly influenced end-of-life decisions. Few physicians sought external ethical advice and decisions were entirely taken by the medical team. Direct involvement of family and treating physician was limited, and the expressed wishes of the patient were generally ignored.Electronic Supplementary Material Supplementary material is available in the online version of this article at .     

The importance of religious affiliation and culture on end-of-life decisions in European intensive care units

Objective To determine the influence of religious affiliation and culture on end-of-life decisions in European intensive care units (ICUs). Design and setting A prospective, observational study of European ICUs was performed on consecutive patients with any limitation of therapy. Prospectively defined end-of-life practices in 37 ICUs in 17 European countries studied from 1 January 1999 to 30 June 2000 were compared for frequencies, patterns, timing, and communication by religious affiliation of physicians and patients and regions. Results Of the 31,417 patients 3,086 had limitations. Withholding occurred more often than withdrawing if the physician was Jewish (81%), Greek Orthodox (78%), or Moslem (63%). Withdrawing occurred more often for physicians who were Catholic (53%), Protestant (49%), or had no religious affiliation (47%). End-of-life decisions differed for physicians between regions and who had any religious affiliation vs. no religious affiliation in all three geographical regions. Median time from ICU admission to first limitation of therapy was 3.2 days but varied by religious affiliation; from 1.6 days for Protestant to 7.6 days for Greek Orthodox physicians. Median times from limitations to death also varied by physician's religious affiliation. Decisions were discussed with the families more often if the physician was Protestant (80%), Catholic (70%), had no religious affiliation (66%) or was Jewish (63%). Conclusions Significant differences associated with religious affiliation and culture were observed for the type of end of life decision, the times to therapy limitation and death, and discussion of decisions with patient families. An erratum to this article can be found at     

Nurse involvement in end-of-life decision making: the ETHICUS Study

Objective The purpose was to investigate physicians perceptions of the role of European intensive care nurses in end-of-life decision making.Design This study was part of a larger study sponsored by the Ethics Section of the European Society of Intensive Care Medicine, the ETHICUS Study. Physicians described whether they thought nurses were involved in such decisions, whether nurses initiated such a discussion and whether there was agreement between physicians and nurses. The items were analyzed and comparisons were made between different regions within Europe.Setting The study took place in 37 intensive care units in 17 European countries.Patients and participants Physician investigators reported data related to patients from 37 centers in 17 European countries.Interventions None.Measurements and results Physicians perceived nurses as involved in 2,412 (78.3%) of the 3,086 end-of-life decisions (EOLD) made. Nurses were thought to initiate the discussion in 66 cases (2.1%), while ICU physicians were cited in 2,438 cases (79.3%), the primary physician in 328 cases (10.7%), the consulting physician in 105 cases (3.4%), the family in 119 cases (3.9%) and the patient in 19 cases (0.6%). In only 20 responses (0.6%) did physicians report disagreement between physicians and nurses related to EOLD. A significant association was found between the region and responses to the items related to nursing. Physicians in more northern regions reported more nurse involvement.Conclusions Physicians perceive nurses as involved to a large extent in EOLDs, but not as initiating the discussion. Once a decision is made, there is a sense of agreement. The level of perceived participation is different for different regions.This article refers to the editorial .     

Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers

OBJECTIVE: Many intensive care unit (ICU) physicians have withdrawn life-support from a patient who lacked decision-making capacity and a surrogate decision-maker, yet little is known about the decision-making practices for these patients. We sought to determine how often such patients are admitted to the ICU of a metropolitan hospital and how end-of-life decisions are made for them. DESIGN: Prospective, observational cohort study. PATIENTS AND SETTING: Consecutive adult patients admitted to the medical ICU of a metropolitan West Coast hospital during a 7-month period in 2003 to 2004. MEASUREMENTS: Attending physicians completed a questionnaire about the decision-making process for each patient for whom they considered limiting life-support who lacked decisional capacity and a legally recognized surrogate decision-maker. MAIN RESULTS: Of the 303 patients admitted during the study period, 49 (16%; 95% confidence interval [CI], 12-21%) lacked decision-making capacity and a surrogate during the entire ICU stay. Compared with all other ICU patients, these patients were more likely to be male (88% vs. 69%; p = .002), white (42% vs. 23%; p = .028), and > or =65 yrs old (29% vs. 13%; p = .007). Physicians considered withholding or withdrawing treatment from 37% (18) of the 49 patients who lacked both decision-making capacity and a surrogate decision-maker. For 56% (10) of these 18 patients, the opinion of another attending physician was obtained; for 33% (6 of 18), the ICU team made the decision independently, and for 11% (2 of 18), the input of the courts or the hospital ethics committee was obtained. Overall, 27% of deaths (13 of 49) during the study period were in incapacitated patients who lacked a surrogate (95% CI, 15-41%). CONCLUSIONS: Sixteen percent of patients admitted to the medical ICU of this hospital lacked both decision-making capacity and a surrogate decision-maker. Decisions to limit life support were generally made by physicians without judicial or institutional review. Further research and debate are needed to develop optimal decision-making strategies for these difficult cases.     

Involvement of nurses in physician-assisted dying

BACKGROUND: Death in modern societies is often preceded by medical end-of-life decisions. Empirical research on these end-of-life decisions focuses predominantly on the physicians' role. Little is known about the role of other health care workers, especially that of nurses. AIM: This paper reports the findings of a study that investigated how often nurses are consulted by physicians in the decision-making process preceding end-of-life decisions and how often nurses participate in administering lethal drugs in end-of-life decisions. METHOD: Data were collected within a nationwide cross-sectional retrospective death certificate study in Flanders, the Dutch-speaking part of Belgium. We selected 3999 deaths, a 20% random sample of all those occurring during the first 4 months of 1998. Anonymous questionnaires were mailed to the physicians who signed the death certificates. Several questions concerned the involvement of nurses in end-of-life decisions. RESULTS: We received 1925 valid questionnaires. For all reported end-of-life decisions (39.3% of all deaths in Flanders), physicians provided information about the involvement of nurses. Physicians consulted at least one nurse in 52% of end-of-life decisions cases occurring in institutions, compared with 21.4% of such cases at home. Nurses administered lethal drugs in 58.8% of euthanasia cases occurring in institutions and in 17.2% at home. For cases in which life was ended without the patient's explicit request because, predominantly, they were too ill to do so, these percentages were respectively 82.7% and 25.2%. In institutions, nurses mostly administered drugs without the attendance of a physician who had prescribed the drugs. CONCLUSIONS: Nurses in Belgium are largely involved in administering lethal drugs in end-of-life decisions, while their participation in the decision-making process is rather limited. To guarantee prudent practice in end-of-life decisions, we need clear guidelines, professionally supported and legally controlled, for the assignment of duties between physicians and nurses regarding the administration of lethal drugs to reflect current working practice. In addition, we need appropriate binding standards governing mutual communication about all end-of-life decisions.     

“Futile” care: Do we provide it? Why? A semistructured,Canada-wide survey of intensive care unit doctors and nurses

PURPOSE: To qualitatively explore the process of the provision of futile care in Canadian intensive care units (ICUs). MATERIALS AND METHODS: A mailed, semistructured survey was sent to medical and nursing unit directors of all Canadian ICUs, asking them to estimate the frequency of provision of futile care, when care becomes "futile," the reasons such care is provided, and the resources that are available to help make end-of-life decisions. Nurse/physician agreement was assessed by chi(2) analysis or Fisher exact test. Content analysis to identify common themes was carried out by 4 raters using a Delphi process. RESULTS: The response rate was 72%. The majority reported futile therapy had been provided in their ICU over the last year (nurses, "N"=95%, physicians, "P"=87%, P=.02). The most commonly stated reasons for providing futile care were family request (N=91%, P=91%, P=NS) and attending physician request (N=91%, P=87% P=NS). Physicians were cited to provide futile care because of prognostic uncertainty (N=73%, P=84%, P=.047) and legal pressures (N=84%, P=75%, P=NS). Comment review revealed 8 main reasons why futile care was provided, the most common of which were that "death was perceived as treatment failure," and poor provider-family communication. Few providers were aware of societal (N=26%, P=51%) or local (22%, all) guidelines relating to the provision of futile care, but of those who were aware, the majority found these useful (range, 73%-74%). Twenty-seven percent expressed the need for someone to discuss difficult ethical issues, such an individual with ethics training specifically assigned to the ICU. CONCLUSIONS: Caregivers voice the opinion that provision of futile care occurs, for multiple reasons, not the least of which is provider-driven. Nurses and physicians of Canadian ICUs perceive the need for increased availability of more ICU-directed and ethically trained resources to help them in providing end-of-life care.     

Surrogate decision-maker for end-of-life care in terminally ill patients at Chiang Mai University Hospital, Thailand

Surrogate decision-maker for end-of-life care is indicated at certain points during care for patients with terminal illnesses. This study aimed at identifying person(s) to whom northern Thai patients with terminal illnesses wished to transfer their decisions on end-of-life care and for cardiopulmonary resuscitation. From interviews with 152 eligible subjects, 57.2% had a high regard for their physicians' authority in making decisions on end-of-life care, 28.3% transferred their decisions to relative(s) and only 14.5% opted for shared decision-making among relative(s) and physicians. In the provision of cardiopulmonary resuscitation, 44.1% of subjects expressed a desire for family to make decisions together with physicians, 33.6% gave directives to the family alone and only 22.4% transferred their decisions to physicians. The differences that were observed in patients' preferences between the two situations indicate that patients should be assessed individually and adequate information for decision-making should be provided.     

End-of-life decisions in the Intensive Care Unit (ICU) – Exploring the experiences of ICU nurses and doctors – A critical literature review

BackgroundEnd-of-life decision making in the Intensive Care Unit (ICU), can be emotionally challenging and multifaceted. Doctors and nurses are sometimes placed in a precarious position where they are required to make decisions for patients who may be unable to participate in the decision-making process. There is an increasing frequency of the need for such decisions to be made in ICU, with studies reporting that most ICU deaths are heralded by a decision to withdraw or withhold life-sustaining treatment.ObjectivesThe purpose of this paper is to critically review the literature related to end-of-life decision making among ICU doctors and nurses and focuses on three areas: (1) Who is involved in end-of-life decisions in the ICU?; (2) What challenges are encountered by ICU doctors and nurses when making decisions?; and (3) Are these decisions a source of moral distress for ICU doctors and nurses?Review methodThis review considered both qualitative and quantitative research conducted from January 2006 to March 2014 that report on the experiences of ICU doctors and nurses in end-of-life decision making. Studies with a focus on paediatrics, family/relatives perspectives, advance care directives and euthanasia were excluded. A total of 12 papers were identified for review.ResultsThere were differences reported in the decision making process and collaboration between doctors and nurses (which depended on physician preference or seniority of nurses), with overall accountability assigned to the physician. Role ambiguity, communication issues, indecision on futility of treatment, and the initiation of end-of-life discussions were some of the greatest challenges. The impact of these decisions included decreased job satisfaction, emotional and psychological ‘burnout’.ConclusionsFurther research is warranted to address the need for a more comprehensive, standardised approach to support clinicians (medical and nursing) in end-of-life decision making in the ICU.     

Characterizing critical care physician staffing in rural America: A description of Iowa intensive care unit staffing

Purpose

This study aimed to characterize intensive care unit (ICU) physician staffing patterns in a predominantly rural state.

Materials and Methods

A prospective telephone survey of ICU nurse managers in all Iowa hospitals with an ICU was conducted.

Results

Of 122 Iowa hospitals, 64 ICUs in 58 (48%) hospitals were identified, and 46 (72%) responded to the survey. Most ICUs (96%) used an open admission model and cared for undifferentiated medical and surgical patients (88%), and only 27% of open ICUs required critical care or pulmonary consultation for admitted patients. Most (59%) Iowa ICUs had a critical care physician or pulmonologist available, and high-intensity staffing was practiced in 30% of ICUs. Most physicians identified as practicing critical care (63%) were not board certified in critical care. Critical care physicians were available in a minority of hospitals routinely for inpatient intubation and cardiac arrest management (29% and 10%, respectively), and emergency physicians and other practitioners commonly responded to emergencies throughout the hospital.

Conclusions

Many Iowa hospitals have ICUs, and staffing patterns in Iowa ICUs mirror closely national staffing practices. Most ICUs are multispecialty, open ICUs in community hospitals. These factors should inform training and resource allocation for intensivists in rural states.     

The involvement of intensive care nurses in end-of-life decisions: a nationwide survey

Objective To investigate the prevalence and predictors of intensive care nurses active involvement in end-of-life (EOL) decisions.Design and setting A survey of intensive care nurses from 36 intensive care units (ICUs) in New Zealand.Measurements and results A total of 611 ICU nurses from 35 ICUs responded to this survey. The response rate was estimated to be between 43% and 81%. Seventy-eight percent of respondents reported active involvement in EOL decisions, especially the senior nurses (level IV vs. I nurses, OR 7.9; nurse educators vs. level I nurses, OR 4.3). Asian (OR 0.2) and Pacific Islander nurses (OR 0.2) were less often involved than European nurses. Sixty-eight percent of respondents preferred more involvement in EOL decisions, and this preference was associated with the perception that EOL decisions are often made too late (OR 2.2). Sixty-five percent believed their active involvement in EOL decisions would improve nursing job satisfaction.Conclusions Most ICU nurses in New Zealand reported that they are often involved in EOL decisions, especially senior and European nurses.     

In-house, overnight physician staffing: a cross-sectional survey of Canadian adult and pediatric intensive care units

OBJECTIVE: Physician staffing is an important determinant of patient outcomes following intensive care unit (ICU) admission. We conducted a national survey of in-house after-hours physician staffing in Canadian ICUs. DESIGN:: Cross-sectional survey. SETTING: Canadian adult and pediatric ICUs. PARTICIPANTS: ICU directors. INTERVENTIONS: ICU directors of Canadian adult and pediatric ICUs were surveyed to describe overnight staffing by interns, residents, critical care medicine trainees, clinical assistants, and ICU physicians in their ICUs. MEASUREMENTS AND MAIN RESULTS: Data were collected regarding hospital and ICU demographics and ICU staffing. For ICUs with in-house overnight physicians, we documented physician experience, shift duration, and clinical responsibilities outside the ICU. We identified 98 Canadian ICU directors, of whom 88 (90%) responded. Dedicated in-house physician coverage overnight was reported in 53 (60%) ICUs, including 13 (15%) in which ICU staff physicians stayed in-house overnight. Compared with ICUs without in-house physicians, those with in-house physicians had more ICU beds (15 vs. 8.5, p=.0001) and fewer ICU staff physicians (5 vs. 7, p=.03). For the 271 physicians who provide overnight staffing, the median level of postgraduate experience was 3 yrs (range, <1 yr, >10 yrs); 129 (48%) had <3 months of ICU experience. Most shifts (83%) were >20 hrs long. CONCLUSIONS: In-house overnight physician staffing in Canadian ICUs varies widely. Only a minority of ICUs comply with the 2003 Society of Critical Care Medicine guidelines for adult ICUs recommending continuous in-house staffing by ICU staff physicians. The duration of most ICU shifts raises concern about workload-associated fatigue and medical error. The impact of current nighttime staffing requires further evaluation with respect to patient outcomes.     

Physician staffing pattern in intensive care units: Have we cracked the code?

Intensive care is slowly being recognized as a separate medical specialization. Physicians, called intensivists, are being specially trained to manage intensive care units (ICUs) and provide focused, high quality care to critically ill patients. However, these ICUs were traditionally managed by primary physicians who used to admit patients in ICUs under their own care. The presence of specially trained intensivists in these ICUs has started a “turf” war. In spite of the availability of overwhelming evidence that intensivists-based ICUs can provide better patient care leading to improved outcome, there is hesitancy among hospital administrators and other policy makers towards adopting such a model. Major critical care societies and workgroups have recommended intensivists-based ICU models to care for critically ill patients, but even in developed countries, on-site intensivist coverage is lacking in a great majority of hospitals. Lack of funds and unavailability of skilled intensivists are commonly cited as the main reasons for not implementing intensivist-led ICU care in most of the ICUs. To provide optimal, comprehensive and skilled care to this severely ill patient population, it is imperative that a multi-disciplinary team approach must be adopted with intensivists as in-charge. Even though ICU organization and staffing may be determined by hospital policies and other local factors, all efforts must be made to attain the goal of having round-the-clock onsite intensivist coverage to ensure continuity of specialized care for all critically ill patients.     

End-of-life care for the critically ill: A national intensive care unit survey

OBJECTIVE: One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. We conducted this study to elicit the views and experiences of ICU directors regarding barriers to optimal end-of-life care and to identify the type, availability, and perceived benefit of specific strategies that may improve this care. DESIGN: Self-administered mail survey. SETTING: Six hundred intensive care units. PARTICIPANTS: A random, nationally representative sample of nursing and physician directors of 600 adult ICUs in the United States. INTERVENTIONS: Mail survey. MEASUREMENTS AND MAIN RESULTS: We asked participants about barriers to end-of-life care (1 = huge to 5 = not at all a barrier), perceived benefit of strategies to improve end-of-life care, and availability of these strategies. From 468 ICUs (78.0% of sample), 590 ICU directors participated (406 nurses [65.1% response] and 184 physicians [31.7% response]). Respondents had a mean of 16.6 yrs (sd 7.6 yrs) of ICU experience. Important barriers to better end-of-life care included patient/family factors, including unrealistic patient/family expectations 2.5 (1.0), inability of patients to participate in discussions 2.7 (0.9), and lack of advance directives 2.9 (1.0); clinician factors, which included insufficient physician training in communication 2.9 (1.1) and competing demands on physicians' time 3.0 (1.1); and institution/ICU factors, such as suboptimal space for family meetings 3.5 (1.2) and lack of a palliative care service 3.4 (1.2). More than 80% of respondents rated 14 of 14 strategies as likely to improve end-of-life care, including trainee role modeling by experienced clinicians, clinician training in communication and symptom management, regular meetings of senior clinicians with families, bereavement programs, and end-of-life care quality monitoring. However, few of these strategies were widely available. CONCLUSIONS: Intensive care unit directors perceive important barriers to optimal end-of-life care but also universally endorse many practical strategies for quality improvement.     

Increased nonbeneficial care in patients spending their birthday in the ICU

Objective

End-of-life decisions are based on objective and subjective criteria. Previous studies identified substantial subjective biases during end-of-life decision-making. We evaluated whether in-ICU patient’s birthday influenced management decisions.

Design

We used a case–control design in which patients spending their birthday in the ICU (cases) were matched to controls on center, gender, age, severity, type of admission, and length of ICU stay before birthday.

Setting

12 ICUs in French hospitals.

Patients

The cases and controls were patients with ICU admissions >48?h over a 10-year period.

Interventions

None.

Measurements and main results

Compared with the 1,042 controls, the 223 cases were more often trauma patients and received a larger number and longer durations of life-sustaining interventions. This increased intensity of life support occurred after, but not before, the birthday. The cases had longer ICU stay lengths. ICU and hospital mortality were not different between the two groups. End-of-life decisions were made in 22% and 24% of cases and controls, respectively. However, these decisions were made later in the cases than in the controls (18 [5–33] versus 9 [3–19]?days).

Conclusions

Our finding that patients who spent their birthday in the ICU received a higher intensity of life-sustaining care and had longer ICU stays but did not have significantly different mortality rates compared with the controls suggests the use of nonbeneficial interventions. Staff members caring for patients whose birthdays fall during the ICU stay should be aware that this feature can bias end-of-life decisions, leading to an inappropriate level of care.     

End of life care in Brazil: the long and winding road

Disagreements between the perceptions of nurses and physicians regarding end-of-life (EOL) decisions are frequent. In a survey carried out in 13 Brazilian ICUs, Fumis and Deheinzelin reported that the majority of nurses, physicians and family members are in favor of limiting life-sustaining therapies in terminally ill patients and that such decisions should involve the ICU team, patients and family members. However, they also observed significant differences among the attitudes when faced with an incompetent patient. The present commentary evaluates the potential implications of the study results, contextualizing with the current scenario surrounding EOL care in Brazil.     

End-of-life intensive care unit decisions,communication, and documentation: an evaluation of physician training

PURPOSE: The majority of patients dying in intensive care units (ICUs) do so after the forgoing of life-sustaining therapies (FLST). Communication between physicians, patients, and their families regarding the decision to FLST has not been evaluated in Israel. MATERIALS AND METHODS: All patients who had FLST in a general ICU were enrolled in the study. We evaluated whether physicians communicated and documented the FLST decisions with patients or the patients' families. We also assessed the effect of the physician's geographic place of training on communication behavior. RESULTS: Over a period of 8.5 months, 385 patients were admitted to a general ICU in Israel. Fifty-seven patients died or had FLST. Twelve of these 57 were excluded from the study. Thus, 45 (79%) patients had FLST and were enrolled in the study. All patients were deemed medically incompetent to make FLST decisions. In 24 (53%) patients, FLST was discussed with the family before the decision to forgo therapy. Discussion occurred later with 6 other families, who were unavailable at the time the FLST decision was made. In 15 patients, there were no discussions with families. American-trained physicians discussed FLST with 22 of 29 families initially and 5 other families later (93%), whereas the Eastern European-trained physicians discussed FLST with only 3 of 16 (19%) families (P <.001). Documentation of FLST was present in 26 (90%) patients of American-trained physicians and 8 (50%) patients of Eastern European-trained physicians (P <.001). CONCLUSIONS: FLST is common in an Israeli ICU. Patients are not medically competent to make FLST decisions. American-trained physicians discuss and document FLST more often than Eastern European-trained physicians.     

Conflict in the care of patients with prolonged stay in the ICU: types,sources, and predictors

Objective To determine types, sources, and predictors of conflicts among patients with prolonged stay in the ICU.Design and setting We prospectively identified conflicts by interviewing treating physicians and nurses at two stages during the patients' stays. We then classified conflicts by type and source and used a case-control design to identify predictors of team-family conflicts.Design and setting Seven medical and surgical ICUs at four teaching hospitals in Boston, USA.Patients All patients admitted to the participating ICUs over an 11-month period whose stay exceeded the 85th percentile length of stay for their respective unit (n=656).Measurements and results Clinicians identified 248 conflicts involving 209 patients; hence, nearly one-third of patients had conflict associated with their care: 142 conflicts (57%) were team-family disputes, 76 (31%) were intrateam disputes, and 30 (12%) occurred among family members. Disagreements over life-sustaining treatment led to 63 team-family conflicts (44%). Other leading sources were poor communication (44%), the unavailability of family decision makers (15%), and the surrogates' (perceived) inability to make decisions (16%). Nurses detected all types of conflict more frequently than physicians, especially intrateam conflicts. The presence of a spouse reduced the probability of team-family conflict generally (odds ratio 0.64) and team-family disputes over life-sustaining treatment specifically (odds ratio 0.49).Conclusions Conflict is common in the care of patients with prolonged stays in the ICU. However, efforts to improve the quality of care for critically ill patients that focus on team-family disagreements over life-sustaining treatment miss significant discord in a variety of other areas.Funding for this study was provided by the Harvard Risk Management Foundation. D.M.S. was also supported in part by grant number KO2HS11285 from the Agency for Healthcare Research and Quality.