Abstract
The French and German cultural and legal decision-making frameworks concerning professional practices at the end of life differ. This has an impact on the way ethical questions are addressed, but it is unclear to what extent such differences also concern “everyday” questions and decisions in the care and treatment of critically ill and dying patients, as they occur especially in intensive care units (ICUs). This contribution draws on results from two parallel qualitative studies in the ICUs, one in France and the other in Germany, concerning the role of time in end-of-life decisions. The results are discussed comparatively against the national legal regulations on Advance Directives as well as the withdrawing and withholding of treatment. Although the legal basis for decisions differs in the two countries, the studies show remarkably similar ethical challenges and problems. It is argued that besides the law, other important factors – such as medical professionalism – might influence physicians’ behaviour in end-of-life decision-making at the ICU and should be given more consideration.
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Notes
- 1.
The French concept of “unreasonable obstinacy” indicates that therapies have been continued beyond what may be considered as reasonable. It is the functional equivalent of the expression “futile treatment”. For an interesting analysis of the difference between the two terms, see Fournier (2017).
- 2.
Law n° 2016-87 of 2 February 2016. (https://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000031970253&categorieLien=id. Accessed 17 February 2020).
- 3.
Translation by authors.
- 4.
Art. L. 1111-11 of n° 2016-87 of 2 February 2016.
- 5.
Marta Spranzi conducted the study as the principal investigator, with two of the Center’s doctors, Véronique Fournier and Nicolas Fouteur.
- 6.
Whereas the “equivalence thesis” for WD and WH is widely considered as ethically justified, there is empirical evidence that doctors perceive WD as more morally problematic than WH. The empirical study is also meant to explore doctors’ preferences and, above all, their reasons for them.
- 7.
Approval from an institutional review board committee is not required in France if interviews do not involve patients.
- 8.
The study was conducted by Anna-Henrikje Seidlein and Sabine Salloch together with Andre Nowak and Matthias Gründling.
References
Alonso, A., D. Dorr, and K. Szabo. 2017. Critical appraisal of advance directives given by patients with fatal acute stroke: An observational cohort study. BMC Medical Ethics 18: 7. https://doi.org/10.1186/s12910-016-0166-5.
Asch, David, and Nicholas Christakis. 1996. Why do physicians prefer to withdraw some forms of life support over others? Medical Care 34: 103–111.
Christakis, Nicholas A., and David A. Asch. 1993. Biases in how physicians choose to withdraw life support. Lancet 342: 642–646. https://doi.org/10.1016/0140-6736(93)91759-f.
Dahmen, Birte Malena, Jochen Vollmann, Stephan Nadolny, and Jan Schildmann. 2017. Limiting treatment and shortening of life: Data from a cross-sectional survey in Germany on frequencies, determinants and patients’ involvement. BMC Palliative Care 16 (3). https://doi.org/10.1186/s12904-016-0176-6.
Ferrand, E., P. Jabre, C. Vincent-Genot, F. Lemaire, C. Brun-Buisson, and J. Marty. 2008. Décisions de limitation et d’arrêts des thérapeutiques actives e réanimation, 7 ans après l’étude LATAREA. Réanimation 17: 51.
Hartog, C.S., and J. Benbenishty. 2015. Understanding nurse-physician conflicts in the ICU. Intensive Care Medicine 41: 331–333. https://doi.org/10.1007/s00134-014-3517-z.
Haute Autorité de Santé. 2018. Guide du parcours de soins: Comment mettre en œuvre une sédation profonde et continue maintenue jusqu’au décès? https://www.has-sante.fr/upload/docs/application/pdf/2018-03/app_164_guide_pds_sedation_web.pdf. Accessed 7 October 2019.
Horn, Ruth. 2013. Euthanasia and end-of-life practices in France and Germany. A comparative study. Medicine, Health Care and Philosophy 16: 197–209. https://doi.org/10.1007/s11019-011-9357-5.
———. 2018. The “French exception”: The right to continuous deep sedation at the end of life. Journal of Medical Ethics 44: 204–205. https://doi.org/10.1136/medethics-2017-104484.
Jox, R.J., M. Krebs, M. Fegg, S. Reiter-Theil, L. Frey, W. Eisenmenger, and G.D. Borasio. 2010. Limiting life-sustaining treatment in German intensive care units: A multiprofessional survey. Journal of Critical Care 25: 413–419. https://doi.org/10.1016/j.jcrc.2009.06.012.
Jox, R.J., R.J. Horn, and R. Huxtable. 2013. European perspectives on ethics and law in end-of-life care. In Handbook of clinical neurology, ed. J.L. Bernat and R. Berevsford, 155–165. Elsevier B.V.
Jozwiak, M., X. Monnet, and J.L. Teboul. 2016. Implementing sepsis bundles. Annals of Translational Medicine 4: 332. https://doi.org/10.21037/atm.2016.08.60.
Kozlowski, D., M. Hutchinson, J. Hurley, J. Rowley, and J. Sutherland. 2017. The role of emotion in clinical decision making: An integrative literature review. BMC Medical Education 17 (1): 255. https://doi.org/10.1186/s12909-017-1089-7.
Langer, S., I. Stengel, S. Fleischer, R. Stuttmann, and A. Berg. 2016. Perspectives on advance directives among German intensive care physicians in leading positions. Deutsche Medizinische Wochenschrift 141: 73–79. https://doi.org/10.1055/s-0042-104038.
Leder, N., D. Schwarzkopf, K. Reinhart, O.W. Witte, R. Pfeifer, and C.S. Hartog. 2015. The validity of advance directives in acute situations. Deutsches Ärzteblatt International 112: 723–729. https://doi.org/10.3238/arztebl.2015.0723.
Lesieur, O., M. Leloup, F. Gonzalez, M.F. Mamzer, and Epilat study group. 2015. Withholding or withdrawal of treatment under French rules: A study performed in 43 intensive care units. Annals of Intensive Care 5: 56. https://doi.org/10.1186/s13613-015-0056-x.
Mayring, P. 2014. Qualitative content analysis: Theoretical foundation, basic procedures and software solution. Klagenfurt.
Mehter, H.M., J.B. McCannon, J.A. Clark, and R.S. Wiener. 2018. Physician approaches to conflict with families surrounding end-of-life decision-making in the intensive care unit. A qualitative study. Annals of the American Thoracic Society 15: 241–249. https://doi.org/10.1513/AnnalsATS.201702-105OC.
Pecanac, K.E., and M.L. Schwarze. 2018. Conflict in the intensive care unit: Nursing advocacy and surgical agency. Nursing Ethics 25: 69–79. https://doi.org/10.1177/0969733016638144.
Petrinec, A.B., and B.R. Martin. 2018. Post-intensive care syndrome symptoms and health-related quality of life in family decision-makers of critically ill patients. Palliative and Supportive Care 16: 719–724. https://doi.org/10.1017/S1478951517001043.
Rietjens, J.A.C., R.L. Sudore, M. Connolly, J.J. van Delden, M.A. Drickamer, M. Droger, A. van der Heide, D.K. Heyland, D. Houttekier, D.J.A. Janssen, L. Orsi, S. Payne, J. Seymour, R.J. Jox, I.J. Korfage, and Care European Association for Palliative. 2017. Definition and recommendations for advance care planning: An international consensus supported by the European Association for Palliative care. Lancet Oncology 18: 543–551. https://doi.org/10.1016/S1470-2045(17)30582-X.
Schweda, M., S. Schicktanz, A. Raz, and A. Silvers. 2017. Beyond cultural stereotyping: Views on end-of-life decision making among religious and secular persons in the USA, Germany, and Israel. BMC Medical Ethics 18: 13. https://doi.org/10.1186/s12910-017-0170-4.
Spranzi, M. 2016. When patients’ values challenge professional integrity. Perspectives in Biology and Medicine 59: 326–336.
Sprung, C.L., S.L. Cohen, P. Sjokvist, M. Baras, H.H. Bulow, S. Hovilehto, D. Ledoux, A. Lippert, P. Maia, D. Phelan, W. Schobersberger, E. Wennberg, T. Woodcock, and Group Ethicus Study. 2003. End-of-life practices in European intensive care units: The Ethicus Study. Journal of the American Medical Association 290: 790–797. https://doi.org/10.1001/jama.290.6.790.
Sprung, C.L., K. Rusinova, and O.T. Ranzani. 2015. Variability in forgoing life-sustaining treatments: Reasons and recommendations. Intensive Care Medicine 41: 1679–1681. https://doi.org/10.1007/s00134-015-3868-0.
Sprung, C.L., B. Ricou, C.S. Hartog, P. Maia, S.D. Mentzelopoulos, M. Weiss, P.D. Levin, L. Galarza, V. de la Guardia, J.C. Schefold, M. Baras, G.M. Joynt, H.H. Bulow, G. Nakos, V. Cerny, S. Marsch, A.R. Girbes, C. Ingels, O. Miskolci, D. Ledoux, S. Mullick, M.G. Bocci, J. Gjedsted, B. Estebanez, J.L. Nates, O. Lesieur, R. Sreedharan, A.M. Giannini, L.C. Fucinos, C.M. Danbury, A. Michalsen, I.W. Soliman, A. Estella, and A. Avidan. 2019. Changes in end-of-life practices in European intensive care units from 1999 to 2016. Journal of the American Medical Association 2: 1–12. https://doi.org/10.1001/jama.2019.14608.
SRLF Commission d’éthique. 2015. Communiqué sur la loi Claeys-Leonetti. Société de Réanimation de Langue Français. https://www.srlf.org/reactu/sur-la-loi-claeys-leonetti-une-avancee-et-des-difficultes-dapplication-qui-concernent-les-reanimateurs/. Accessed 7 Oct 2019.
Van Beek, K., K. Woitha, N. Ahmed, J. Menten, B. Jaspers, Y. Engels, S.H. Ahmedzai, K. Vissers, and J. Hasselaar. 2013. Comparison of legislation, regulations and national health strategies for Palliative care in seven European countries (results from the Europall Research Group): A descriptive study. BMC Health Services Research 13: 275. https://doi.org/10.1186/1472-6963-13-275.
van Beinum, A., L. Hornby, R. Ward, T. Ramsay, and S. Dhanani. 2015. Variations in the operational process of withdrawal of life-sustaining therapy. Critical Care Medicine 43: 450–457. https://doi.org/10.1097/CCM.0000000000001163.
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Seidlein, AH., Salloch, S., Spranzi, M. (2022). The Role of Time in End-of-Life Decision-Making at the Intensive Care Unit in France and Germany: Qualitative-Empirical Data and Ethical Reflection. In: Seidlein, AH., Salloch, S. (eds) Ethical Challenges for Healthcare Practices at the End of Life: Interdisciplinary Perspectives. Philosophy and Medicine, vol 141. Springer, Cham. https://doi.org/10.1007/978-3-030-83186-8_5
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