Decision-Making. Seventeen percent of respondents replied that decisions made regarding terminal care involved the full ICU staff, and 49% said that such decisions involved staff, patient, and/or family. Decisions were more commonly made by physicians in Italy, Greece, and Portugal and by the ICU staff as a whole in the United Kingdom and Switzerland. Forty-five percent of respondents felt that an ethics consultation would be useful in making such decisions, and this was most commonly felt in Spain, Greece, Italy, and Portugal. Fewer physicians in the United Kingdom and Scandinavia felt that an ethics consultation would be useful. In general, physicians from units with fewer than 7 beds were more likely to feel that an ethics consultation would be useful than physicians from larger units (57% in units with fewer than 7 beds vs. 33% in units with more than 18 beds; p < .03).
Ethical Issues. Forty-two percent of respondents felt that ethical issues were medical issues, 17% felt that they were essentially patient/family issues, and 41% felt that they should involve everyone.
Example. An example was presented of a 40-yr-old man with postanoxic coma after a cardiac arrest secondary to a myocardial infarction. Six days after this event, he is still in a profound coma, breathing spontaneously through a T-piece. If the patient had no family, 49% of respondents would withhold additional therapy and 29% would withdraw treatment. Seventeen percent of respondents would administer sedation to speed death. The figures were more influenced by the family when they expressed the wish that everything possible should be done than when they wanted therapy withdrawn (Table 7). The religious belief of physicians influenced their responses to this example. With the family insisting on withholding and withdrawal, 58% of respondents considering themselves religious would continue full support, compared with 50% of the nonreligious respondents (p < .05). Conversely, 33% of the nonreligious respondents would administer sedation to speed death, compared with only 11% of the religious respondents (p < .05). Again, there were marked differences between countries (Table 7). In particular, 33% of physicians from Greece said that they would continue all treatment even when the family insisted on withholding or withdrawing, whereas none of their counterparts from Portugal, Scandinavia, Switzerland, and the United Kingdom said that they would continue treatment in this situation (p < .01).
In 1990, I published the results of a questionnaire  that highlighted different attitudes to various ethical issues among physicians from different countries and of different ages and religious backgrounds. The current study updates and extends these earlier results with a much larger database, separating some countries that were discussed together in the previous paper, i.e., Spain and Portugal, Austria and Germany. All questionnaires received were anonymous; therefore, the results are expected to be an accurate reflection of attitudes. Although questions were directed at identifying current practice in different European ICUs, the questionnaire asked not only what is happening but also asked for opinions regarding what should be happening to explore differences in individual beliefs and attitudes.
Ethics is a subjective concept and as such eludes precise definition. However, one can say that, in general, ethics is a system of moral principles governing conduct, and more particularly, that it refers to the specific moral choices an individual makes in interacting with others. The intensivist is frequently faced with ethical dilemmas in which a choice must be made between two seemingly negative options, e.g., the decision to continue life support and maintain a life of poor quality or to withdraw therapy with the almost inevitable resultant death of the patient. Numerous factors may influence the final moral decision, including the age and experience of the physician, the physician's training and religious background, peer and family pressure, the age and perceived quality of life of the patient, and patient wishes [15,16]. The ethos of the sanctity of life is firmly embedded in society, and issues regarding end-of-life decisions are frequently controversial. The power of the physician as prime decision-maker is increasingly questioned as the rights of the individual to choose whether to receive or forgo life-sustaining treatments are promoted. Too often in the ICU setting, patients are not fit to state their preferences and wishes [17-19], and family members, the physician and ICU staff, or another appointed surrogate must act on the patient's behalf [4,12].
Increasingly expensive modern technology and therapies have made the ICU a costly department, consisting of 5% to 10% of the hospital beds but using 20% to 35% of the hospital budget. Increasingly, the emphasis is being placed on rationalizing intensive care facilities, with the ever-present threat of rationing if available funds are exceeded . In the present survey, ICU admissions were frequently limited by lack of beds, particularly in Greece, Italy, Portugal, and the United Kingdom, and yet three-fourths of physicians still admit patients with no hope of survival for more than a few weeks. This Figure ishigher than that reported in a study from the United States, in which 54% of American physicians said that they would admit patients with no hope of survival for more than a few weeks , but both figures suggest that this is an area that needs to be rationalized. In the present survey, younger physicians in particular were more likely to admit patients with no hope of survival, although only one-third of all physicians felt that such patients should be admitted. Patients with a poor quality of life and a poor prognosis were also frequently admitted. Such patients often do not benefit from intensive care and incur the highest costs , but it is difficult to make an objective decision not to admit them. Attempts have been made to define the "futile" patient [23,24] or the point at which care becomes "futile" , but ultimately priority for admission must correlate with the likelihood that ICU care will benefit the patient more than non-ICU care . One of the problems with defining futility is the lack of an objective means of assessing outcome, because available scores to predict outcome make no allowance for quality of life or morbidity. These systems may be useful in decisions regarding treatment when a patient is already in the ICU, but they offer no assistance in the initial decision of whether or not to admit that patient . With almost half of the respondents stating that ICU admissions are commonly or generally limited by lack of beds, particularly in the south and the United Kingdom, where units are generally smaller than elsewhere in Europe, guidelines need to be established and implemented to effectively limit the admission of patients who will not benefit from ICU care and free these beds for the patients who need them most. Such recommendations have been established in the United States, where the Society of Critical Care Medicine has published a list of diagnostic categories that do not merit ICU admission . Increasing the number of available ICU beds will be cost effective only if admission and discharge criteria are carefully considered and enforced to limit costly ICU interventions to those who will benefit from them.
The application of DNR orders varies considerably among countries and physicians. The majority of physicians did apply written or oral orders, although this occurred more commonly in the countries of northern Europe (The Netherlands, Scandinavia, and Switzerland) than in Italy, Portugal, or Greece. It is interesting to speculate why physicians might not apply a written DNR order. Physicians are increasingly aware of litigation, and it may be that fear of legal action influences the decision to resuscitate even in the presence of a clearly written DNR order . Most physicians would discuss DNR orders with the patient's family, but fewer would discuss such orders with the patient, although this may be influenced by the fact that many ICU patients may be unable to participate in such discussions because of the severity of their illness or even unconsciousness [17-19,27]. Female physicians and Catholic physicians were, in particular, less likely to discuss DNR orders with the patients. Physicians from The Netherlands were more likely to discuss orders with patients than physicians from any other country, which may be related to that country's more liberal policies on terminal care . DNR orders are frequently obtained late in a patient's ICU stay [29,30], when the patient is perhaps already incompetent and family members are under the stress of the impending death. The recent SUPPORT study (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment) , based in five American hospitals, reported that 46% of DNR orders were written within 2 days of a patient's death and that the median length of hospital stay before a DNR order was written varied from 22 to 73 days. Although difficult, attempts to discuss such issues with patients and family members on admission would allow for specific requests and advance directives to be documented, facilitating end-of-life decisions when the time came. In the present survey, three-fourths of DNR orders were discussed with the family and just one-fourth were discussed with the patient, similar to results from some other studies [31,32]. However, in one study from Japan , although all DNR orders were discussed with the family, only 5% were discussed with the patient, and in the SUPPORT study , 37% of patients reported having discussed resuscitation with the physician, although 40% of patients who did not have such a discussion would have liked one. In the present study, the number of physicians who felt that DNR orders should be discussed with the patient or family was much higher than the actual situation would suggest. Similarly, in the United States, although 95% of physicians in one study felt that patient consultation was appropriate , only 19% of patients undergoing resuscitation and 33% of their families had been consulted. Such disparities between what physicians feel should be done and what actually occurs suggests that such issues are difficult and therefore tend to be postponed or not raised. However, there is evidence that discussions of these topics become easier if they are carried out more frequently , and perhaps they should become a routine part of ICU admission protocols.
The presence of a DNR order often precedes the decision to withdraw or withhold treatment [1,7]. The withdrawal/withholding of therapy and life-support systems is an open field for ethical debate, and discussion is often complicated by problems of definition and terminology . Increasing financial restraints within health care systems encourage us to define and limit the administration of futile treatments. Although it is generally agreed that there is no legal or moral difference between the principles of withdrawing and withholding [6,34-36], a perceived difference still exists, with fewer physicians willing to withdraw treatment already instituted than to refrain from initiating therapy [14,16,30]. Several studies have reported that patients die more rapidly after withdrawal than after withholding of therapy [1,30], and this observation may explain physicians' perception of a difference between withholding and withdrawing. Older physicians in the present survey were more likely than younger physicians to feel that therapy should sometimes be withdrawn from patients with no chance of regaining a meaningful life. Within Europe, physicians from Greece and Portugal are less likely to withdraw therapy than their northern counterparts, and similarly, physicians from Italy and Portugal are less likely to administer large doses of drugs until death ensues than physicians from France and Belgium. Cultural, religious, and legal differences certainly play an important role in determining an individual's attitude to these issues . In the present survey, Catholic physicians were less likely to withhold and withdraw therapy than their Protestant or agnostic colleagues. In Israel, the withholding of treatment is common, but withdrawal of life-sustaining therapy, which is not permitted under Jewish law, occurs much less frequently . The withdrawing and withholding of treatment have become more common since the previous questionnaire  (93% vs. 83% for withholding, and 77% vs. 63% for withdrawing), perhaps reflecting a more general acceptance of these practices by the medical profession in Europe. The figures from these surveys support those from other studies showing that the withholding and withdrawal of life-sustaining therapies are commonly practiced worldwide [16,18,27,38,39]. A recent study in the United States  found that there had been an increase in the recommendation to withdraw or withhold therapy from ICU patients from 51% in 1987/1988 to 91% in 1992/1993, and other authors  have also reported an increase in DNR orders and terminal wean decisions. Indeed, the majority of deaths in the ICU now occur after the withdrawal of life-sustaining therapies [2,19,40]. The deliberate administration of drugs until death ensues has not markedly increased (36% in 1990 , 40% in this study), although studies from The Netherlands  on medical practices concerning the end of life have documented an increase in euthanasia in the last 5 yrs. These issues are still highly emotional, and in general, withdrawal is considered more acceptable than direct drug administration because it is perceived, in the present study and in other studies , to be allowing the patient to die rather than killing the patient. This opinion was the same regardless of religious background, but more physicians who consider themselves religious felt that both withdrawing treatment and euthanasia were unacceptable than did the nonreligious physicians.
Decisions in terminal care were made by the ICU staff alone in almost one-fifth of all cases, and the patient or family was involved less than half the time. Western society still considers death to be a somewhat taboo subject, and it is sometimes easier to discuss it with colleagues than with the patient and family . This is further reflected in the finding that almost half of the physicians questioned replied that they felt that ethical issues are predominantly medical issues and decisions should be made by the physician. This is particularly true within Europe, and it represents a recognized difference with our colleagues in the United States, where patient autonomy and the patient's decision to undergo or refuse treatment are considered to be fundamental rights and are accepted as such by the medical profession. However, despite the importance of patient autonomy in the American system, the SUPPORT study  noted marked deficiencies in communication between physicians and patients. Other studies from the United States, however, have reported that the majority of end-of-life decisions are indeed made in conjunction with the family/surrogate and/or patient [19,43]. An ethics consultant can be an independent onlooker who may facilitate such decision-making; offer advice in a particularly difficult case; mediate between staff, family, and patient in cases in which communication has broken down; and be involved in the teaching of ethics and communication to staff members. Forty-five percent of intensivists felt that an ethics consultation could help in such decisions, an increase from the 38% observed in the previous survey . Physicians in the southern countries were more likely to value the input of an ethics consultant, which may reflect the particular difficulties that physicians in the south face with regard to difficult ethical decisions. The stronger religious backgrounds and influences in these countries may make such issues more complicated, and the experience of specially trained people or panels may be consequently more appreciated. Physicians from smaller units were more likely to feel that an ethics consultation could be helpful than physicians from larger units, which may reflect the increased opportunity for discussion of such decisions with colleagues in larger units than in smaller units, where physicians may feel more isolated and thus in greater need of help from an independent ethics consultant.
There are always limitations associated with questionnaire surveys, and interpretation of the data received must take these into account. Although the response rate in the present study was only 39%, questionnaires were received from a broad cross-section of European countries, from ICUs of different size, and from intensivists of varying age, sex, and background. Therefore, I believe the results obtained to be representative of the situation in Europe. Replies inevitably tend to be furnished by the most motivated physicians, but this occurs across the board; therefore, comparisons between countries can still be made. Another factor in a questionnaire investigating subjective beliefs and thoughts is that the way in which a question is worded may influence its interpretation and hence the results, particularly when many of the respondents' first language is not English. Finally, a questionnaire relies on the answers furnished and not on direct observation of actions. However, because the questionnaires are anonymous, there is no reason to believe that the replies are different from the actual situation.
Bearing in mind these possible limitations, important information can be derived regarding some of the various ethical issues facing the western European intensivist. With current financial pressures, it is surprising that despite frequently limited bed availability, almost three-fourths of ICUs admit patients with no hope of survival. The withdrawal and withholding of therapy are practiced commonly, reflecting the situation worldwide. Two-fifths of physicians admit to sometimes deliberately administering drugs to patients with no hope of survival until death ensues. Additionally, significant differences exist among intensivists from different European countries, with a particular distinction between the southern countries of Greece, Italy, Portugal, and Spain and the northern countries. The application of DNR orders, withdrawal of therapy, and the deliberate administration of drugs until death ensues were all less common in the south. In these southern countries, end-of-life decisions are more commonly made by the medical staff with little patient involvement, but physicians there are more likely to value input from an ethics consultant. The quandary many physicians experience when faced with a complex ethical decision is reflected in the questionnaire by the often large differences between what a physician does when faced with a particular situation and what he or she feels should be done. Ethical issues are frequently faced by the intensivist, yet little training on how to manage often complex decisions is provided in medical school or elsewhere. Articles such as this encourage discussion of these issues and support the need for guidelines to assist in ethical decisionmaking.
APPENDIX: RELEVANT QUESTIONS FROM THE QUESTIONNAIRE
A. Do/should you sometimes admit to the ICU a patient
1. with no hope of survival for more than a few weeks?
2. who may live for several years but whose quality of life is very poor according to your opinion?
3. who may live for several years but whose quality of life is very poor according to the patient's definition?
4. with very limited chances of survival (or poor prognostic index if calculated)?
B. Is ICU admission limited by the number of available beds
2. often, commonly?
3. sometimes, uncommonly?
4. (almost) never?
C. Do/should you currently apply DNR orders in the event of cardiac arrest?
1. Yes, written DNR orders.
2. Yes, oral DNR orders.
3. No. These orders would limit the level of care to these patients.
4. No. One should attempt to resuscitate every patient in the ICU.
D. If DNR orders are used, are/should they be, as a general rule discussed
1. with the patient?
2. with the family?
E. In patients with no real chance of recovering a meaningful life, do/should you sometimes
1. withhold sophisticated therapy (i.e., not start mechanical ventilation, dialysis, etc)?
2. withdraw sophisticated therapy (i.e., discontinue mechanical ventilation, dialysis, etc.)?
3. deliberately administer large doses of medication (e.g., barbiturates or morphine) until death ensues?
F. Please select the most appropriate statement (read them all!) concerning attitudes toward hopeless patients.
1. Withdrawal of minimal support (i.e., intravenous fluids and feeding) vs. euthanasia (administration of medication to provoke death):
a. The first is more acceptable than the second because it is "letting die" rather than "killing."
b. Both surely lead to death, so the second might be preferred to avoid suffering.
c. Both are unacceptable.
2. Limited care (withholding therapy) vs. withdrawal or euthanasia:
a. These have become unavoidable in some patients. Whenever possible, withholding therapy is preferable.
b. These have become unavoidable in some patients. Limited care is generally very difficult and sometimes hazardous. Maximal treatment should be provided and withdrawn if the situation becomes hopeless.
c. Neither can be accepted. The ICU physician should preserve life at all costs.
G. The decision about terminal care does/should involve
1. the medical staff.
2. the ICU staff (including nurses).
3. the patient and/or family.
H. Can an ethics consultant (or committee) help in these decisions?
I. What is the most appropriate statement regarding ethical issues?
1. These are essentially medical issues. Therefore, the physician in general should decide.
2. These are issues involving essentially the patient and/or his/her family, who should in general decide.
3. These are issues involving everybody. Therefore, they should involve specially designated persons (hospital committee, ethical consultant, etc.).
J. A 40-yr-old man without previous disease has a cardiac arrest secondary to extended myocardial infarction. Six days later, he is still in profound coma with decerebrate movements. A neurologist agrees that the patient has no chance to recover. The patient breathes spontaneously via a T-piece. Select your attitude in each of the three following conditions.
1. The patient has no family.
2. The family insists on withhold and withdraw.
3. The family insists that everything be done.
a. Continue full support, including mechanical ventilation if required.
b. Withhold additional therapy (including mechanical ventilation or antibiotics if required), but continue care.
c. Discontinue treatment (including intravenous fluids, feeding) and allow the patient to die slowly (ensure minimal comfort medication if required).
d. Administer sedation/morphine to allow the patient to die rapidly.
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