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.