Abstract
Purpose
To compare the attitudes of physicians towards withholding and withdrawing life-sustaining treatments in intensive care units (ICUs) in low-middle-income Asian countries and regions with those in high-income ones, and to explore differences in the role of families and surrogates, legal risks, and financial considerations between these countries and regions.
Methods
Questionnaire study conducted in May–December 2012 on 847 physicians from 255 ICUs in 10 low-middle-income countries and regions according to the World Bank’s classification, and 618 physicians from 211 ICUs in six high-income countries and regions.
Results
After we accounted for personal, ICU, and hospital characteristics on multivariable analyses using generalised linear mixed models, physicians from low-middle-income countries and regions were less likely to limit cardiopulmonary resuscitation, mechanical ventilation, vasopressors and inotropes, tracheostomy and haemodialysis than those from high-income countries and regions. They were more likely to involve families in end-of-life care discussions and to perceive legal risks with limitation of life-sustaining treatments and do-not-resuscitate orders. Nonetheless, they were also more likely to accede to families’ requests to withdraw life-sustaining treatments in a patient with an otherwise reasonable chance of survival on financial grounds in a case scenario (adjusted odds ratio 5.05, 95 % confidence interval 2.69–9.51, P < 0.001).
Conclusions
Significant differences in ICU physicians’ self-reported practice of limiting life-sustaining treatments, the role of families and surrogates, perception of legal risks and financial considerations exist between low-middle-income and high-income Asian countries and regions.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD (2010) Critical care and the global burden of critical illness in adults. Lancet 376:1339–1346
Yaguchi A, Truog RD, Curtis JR, Luce JM, Levy MM, Melot C, Vincent JL (2005) International differences in end-of-life attitudes in the intensive care unit: results of a survey. Arch Intern Med 165:1970–1975
Vincent JL (1990) European attitudes towards ethical problems in intensive care medicine: results of an ethical questionnaire. Intensive Care Med 16:256–264
Vincent JL (1999) Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med 27:1626–1633
Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, Ledoux D, Lippert A, Maia P, Phelan D, Schobersberger W, Wennberg E, Woodcock T (2003) End-of-life practices in European intensive care units: the Ethicus Study. JAMA 290:790–797
Azoulay E, Metnitz B, Sprung CL, Timsit JF, Lemaire F, Bauer P, Schlemmer B, Moreno R, Metnitz P (2009) End-of-life practices in 282 intensive care units: data from the SAPS 3 database. Intensive Care Med 35:623–630
Cook D, Rocker G, Marshall J, Sjokvist P, Dodek P, Griffith L, Freitag A, Varon J, Bradley C, Levy M, Finfer S, Hamielec C, McMullin J, Weaver B, Walter S, Guyatt G (2003) Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 349:1123–1132
Mark NM, Rayner SG, Lee NJ, Curtis JR (2015) Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med 41:1572–1585
Eyssallenne AP (2012) How far do you go? Intensive care in a resource-poor setting. N Engl J Med 367:8–9
Dunser MW, Baelani I, Ganbold L (2006) A review and analysis of intensive care medicine in the least developed countries. Crit Care Med 34:1234–1242
Frost DW, Cook DJ, Heyland DK, Fowler RA (2011) Patient and healthcare professional factors influencing end-of-life decision-making during critical illness: a systematic review. Crit Care Med 39:1174–1189
Wilkinson DJ, Truog RD (2013) The luck of the draw: physician-related variability in end-of-life decision-making in intensive care. Intensive Care Med 39:1128–1132
Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, Hinds C, Pimentel JM, Reinhart K, Thompson BT (2004) Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med 30:770–784
Pope TM, Hexum M (2012) Legal briefing: POLST: physician orders for life-sustaining treatment. J Clin Ethics 23:353–376
Luce JM, White DB (2009) A history of ethics and law in the intensive care unit. Crit Care Clin 25:221–237
Phua J, Joynt GM, Nishimura M, Deng Y, Myatra SN, Chan YH, Binh NG, Tan CC, Faruq MO, Arabi YM, Wahjuprajitno B, Liu SF, Hashemian SM, Kashif W, Staworn D, Palo JE, Koh Y, ACME Study Investigators and the Asian Critical Care Clinical Trials Group (2015) Withholding and withdrawal of life-sustaining treatments in intensive care units in Asia. JAMA Intern Med 175:363–371
Kim J, Asia-Pacific Global Research Group (2013) How Asians say “no” (without saying it): top 5 indirect “no’s”. http://asiapacificglobal.com/2013/05/how-asians-say-no-without-saying-it-top-5-indirect-nos/. Accessed 30 Jan 2016
The World Bank (2012) Newest country classifications released. http://data.worldbank.org/news/newest-country-classifications-released. Accessed 9 Oct 2015
World Health Organization (2014) Global health expenditure database: national health accounts indicators. http://apps.who.int/nha/database/DataExplorerRegime.aspx. Accessed 1 July 2014
Food and Health Bureau, the Government of the Hong Kong Special Administrative Region (2015) Hong Kong’s Domestic Health Accounts (HKDHA)—estimate of domestic health expenditure, 1989/90–2010/11. http://www.fhb.gov.hk/statistics/en/dha.htm. Accessed 9 Oct 2015
Ministry of Health and Welfare, Taiwan (2013) National health expenditure—2012. http://www.mohw.gov.tw/EN/Ministry/Statistic.aspx?f_list_no=474&fod_list_no=4535. Accessed 9 Oct 2015
Cook DJ, Guyatt GH, Jaeschke R, Reeve J, Spanier A, King D, Molloy DW, Willan A, Streiner DL (1995) Determinants in Canadian health care workers of the decision to withdraw life support from the critically ill. Canadian Critical Care Trials Group. JAMA 273:703–708
Christakis NA, Asch DA (1995) Physician characteristics associated with decisions to withdraw life support. Am J Public Health 85:367–372
Sprung CL, Truog RD, Curtis JR, Joynt GM, Baras M, Michalsen A, Briegel J, Kesecioglu J, Efferen L, De Robertis E, Bulpa P, Metnitz P, Patil N, Hawryluck L, Manthous C, Moreno R, Leonard S, Hill NS, Wennberg E, McDermid RC, Mikstacki A, Mularski RA, Hartog CS, Avidan A (2014) Seeking worldwide professional consensus on the principles of end-of-life care for the critically ill. The Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) study. Am J Respir Crit Care Med 190:855–866
Salahuddin N, Shafqat S, Mapara S, Khan S, Siddiqui S, Manasia R, Ahmad A (2008) End of life in the intensive care unit: knowledge and practice of clinicians from Karachi, Pakistan. Intern Med J 38:307–313
Mani RK, Mandal AK, Bal S, Javeri Y, Kumar R, Nama DK, Pandey P, Rawat T, Singh N, Tewari H, Uttam R (2009) End-of-life decisions in an Indian intensive care unit. Intensive Care Med 35:1713–1719
Kapadia F, Singh M, Divatia J, Vaidyanathan P, Udwadia FE, Raisinghaney SJ, Limaye HS, Karnad DR (2005) Limitation and withdrawal of intensive therapy at the end of life: practices in intensive care units in Mumbai, India. Crit Care Med 33:1272–1275
Yazigi A, Riachi M, Dabbar G (2005) Withholding and withdrawal of life-sustaining treatment in a Lebanese intensive care unit: a prospective observational study. Intensive Care Med 31:562–567
Gawande AA (2014) Being mortal: illness, medicine and what matters in the end. Metropolitan Books, New York
Koh M, Hwee PC (2015) End-of-life care in the intensive care unit: how Asia differs from the West. JAMA Intern Med 175:371–372
Aslakson RA, Curtis JR, Nelson JE (2014) The changing role of palliative care in the ICU. Crit Care Med 42:2418–2428
Worldwide Palliative Care Alliance (2014) Global atlas of palliative care at the end of life. http://www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf. Accessed 20 Oct 2015
Barnett VT, Aurora VK (2008) Physician beliefs and practice regarding end-of-life care in India. Indian J Crit Care Med 12:109–115
Hillman KM, Cardona-Morrell M (2015) The ten barriers to appropriate management of patients at the end of their life. Intensive Care Med 41:1700–1702
Cheng B, Xie G, Yao S, Wu X, Guo Q, Gu M, Fang Q, Xu Q, Wang D, Jin Y, Yuan S, Wang J, Du Z, Sun Y, Fang X (2007) Epidemiology of severe sepsis in critically ill surgical patients in ten university hospitals in China. Crit Care Med 35:2538–2546
Chan HM (2004) Sharing death and dying: advance directives, autonomy and the family. Bioethics 18:87–103
Kwak J, Haley WE (2005) Current research findings on end-of-life decision making among racially or ethnically diverse groups. Gerontologist 45:634–641
Puntillo K, Nelson JE, Weissman D, Curtis R, Weiss S, Frontera J, Gabriel M, Hays R, Lustbader D, Mosenthal A, Mulkerin C, Ray D, Bassett R, Boss R, Brasel K, Campbell M, Advisory Board of the Improving Palliative Care in the ICUP (2014) Palliative care in the ICU: relief of pain, dyspnea, and thirst—a report from the IPAL-ICU Advisory Board. Intensive Care Med 40:235–248
Bulow HH, Sprung CL, Baras M, Carmel S, Svantesson M, Benbenishty J, Maia PA, Beishuizen A, Cohen S, Nalos D (2012) Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The Ethicatt study. Intensive Care Med 38:1126–1133
Acknowledgments
List of Asian Collaboration for Medical Ethics (ACME) Study Collaborators, the Asian Critical Care Clinical Trials (ACCCT) Group
Key Collaborators
Hong Kong: Charles D Gomersall, F.R.C.P., Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital
China: Bin Du, M.D., Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing
India: Jigeeshu V Divatia, M.D., Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai
Taiwan: Mei-Lien Tu, R.R.T., Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung
Thailand: Boonsong Patjanasoontorn, M.D., Division of Respiratory and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Khonkaen University, Khonkaen
Collaborators and Site Investigators
Bangladesh: Community Medical College and Hospital: U H Shahera Khatun; Holy Family Red Crescent Hospital: Md Abdul Mannan; Square Hospital: Mirza Nazim Uddin; Central Hospital: Raghib Manzoor; United Hospital: Mohammad Maniruzzaman; BIRDEM General Hospital: ASM Areef Ahsan, Kaniz Fatema, Fatema Ahmed; Square Hospital: ARM Nooruzzaman; Institute of Epidemiology, Disease Control and Research: Asif Mujtaba Mahmud; Anwar Khan Modern Hospital: SM Hossain Shahid; Uttara Crescent Hospital: Rownak Jahan Tamanna; National Institute of Chest Diseases and Hospital: Md Sayedul Islam; Chittagong Medical College Hospital: AKM Shamsul Alam; Medical College for Women and Hospital: Abdul Karim; Ibn Sina Hospital, Sylhet: Mohammad Rashed Mahmud; Ctg Metropolitan Hospital: Rashed Chowdhury; Lab Aid Hospital: Mohammad Faruk; Ibrahim Cardiac Hospital and Research Institute: Md Rezaul Karim; Renaissance Hospital: Sarwar Iqbal: BSM Medical University: Qumrul Huda
China: Peking Union Hospital: Bin Du; The Affiliated Zhongda Hospital of Dongnan University: Haibo Qiu; The 10th Affiliated Hospital of Tongji University: Xiangyu Zhang; Sichuan People‘s Hospital: Yun Dong; The Affiliated Hospital of North Sichuan Medical College: Yong Wan; The Affiliated Hospital of Luzhou Medical College: Cihai Gan; Deyang People‘s Hospital: Yawei Zhang; The Affiliated Hospital of Chengdu University of Traditional Chinese Medicine: Peiyang Gao; Chengdu Contagious Hospital: Hong Chen; Mianyang Central Hospital: Chao Jia; The 2nd Neijiang People‘s Hospital: Xianhua Xiao; Meishan People‘s Hospital: Nutao Xiang; The 4th Zigong People‘s Hospital: Jingsong Li; The 2nd Affiliated Hospital of Jilin University: Yushan Wang; The Affiliated Ruijin Hospital of Shanghai Jiao Tong University: Yaoqing Tang; Zhongnan Hospital of Wuhan University: Jianguo Li; The People’s Hospital of Beijing University: Youzhong An; The 1st Affiliated Hospital of Chinese Medical University: Xiaochun Ma; The 1st Affiliated Hospital of Xi’an Jiao Tong University: Xue Wang; The 4th Hospital of Hebei Medical University: Zhenjie Hu; Guangdong People‘s Hospital: Tiehe Qin
Hong Kong: Caritas Medical Centre: Fu Loi Chow; Kwong Wah Hospital: Chi Lung Watt; North District Hospital: KK Wong; Pamela Youde Nethersole Eastern Hospital: Wing-Wa Yan; Prince Margaret Hospital: Tom Buckley; Queen Elizabeth Hospital: Kang Yiu Lai; Queen Mary Hospital, Pokfulam: Karl Young; Tseung Kwan O Hospital: Chi Keung Ching; United Christian Hospital: Kin-Ip Law
India: Tata Memorial Hospital, Mumbai: Jigeeshu Vasishtha Divatia; PD Hinduja National Hospital and Medical Research Centre, Mumbai: Farhad N Kapadia; Apollo Hospitals Chennai: Nagarajan Ramakrishnan; Fortis Hospital Noida: Mrinal Sircar; Bombay Hospital Institute of Medical Sciences: Pravin Amin; Amrita Institute of Medical Sciences, Kochi: Charu Singh; Indraprastha Apollo Hospital, New Delhi: Rajesh Chawla; Saket City Hospital: Raj Kumar Mani; Alchemist Hospital, Panchkula: Ashwani Nayyar; Bharati Hospital and Research Centre, Pune: Jignesh Shah
Indonesia: Siloam Hospitals Lippo Village: Oloan Tampubolon; Dr. Hasan Sadikin Hospital: Tinni T. Maskoen
Iran: Masih Daneshvari Hospital: Hamidreza Jamaati; Shohada Tajrish Hospital: Farahnaz Fallahian, Badiozaman Radpay, Alireza Zali; Shahid Rajaee Hospital: Ahmad Bagheri
Japan: Hiroshima City Hospital: Keiichi Tada; Nagasaki University School of Medicine: Toshiaki Nakamura; Jikei University School of Medicine: Masamitsu Sanui; Osaka University Hospital: Yuji Fujino; Kagawa University: Gotaroh Shiragami; Hyogo Medical School: Joji Kotani; Fukuyama City Hospital: Kohji Miyasho; Keio University: Hiroshi Morisaki; Shiga Medical School: Yutaka Eguchi; Nihon Medical School Hospital: Shinhiro Takeda; Osaka Prefecture Hospital: Shinya Nishimura; Fujita Health University: Osamu Nishida; Hiroshima University: Koichi Tanigawa; Toyonaka City Hospital: Koji Takada; Chiba University: Sigeto Oda; Kurashiki Central Hospital: Toshio Fukuoka; Tokai University: Toru Sawamoto; Kyoto Prefecture University Hospital: Satoru Hashimoto; Nagoya City University: Kazuya Sobue; Kochi Red Cross Hospital: Kingo Nishiyama; Okayama University: Kiyoshi Morita; Tosei Hospital: Hiroyuki Taniguchi; Asahikawa Red Cross Hospital: Shinzo Sumita
Malaysia: Seremban Hospital: Jenny May Geok Tong
Pakistan: Aga Khan University: Madiha Hashmi, Dreema Awan
Philippines: University of Santo Tomas Hospital, Manila: Larry S King
Saudi Arabia: King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh: Hasan M Al-Dorzi, Musharaf Sadat; King Saud Bin Abdulaziz University for Health Sciences, Jeddah: Fahad M Al-Hameed
Singapore: Alexandra Hospital: Chee Keat Tan; Changi General Hospital: Augustine Tee, E-Lin Ooi; National University Hospital: Addy YH Tan; Tan Tock Seng Hospital: Yeow Chan, Benjamin Ho; Khoo Teck Puat Hospital: Azman Johan; Singapore General Hospital: Chai Rick Soh
South Korea: Yonsei University Medical Center, Yonsei University College of Medicine: Cheung Soo Shin; Hanyang University Hospital, Hanyang University College of Medicine: Jong Hun Jun; Chonnam National University Hospital, Chonnam National University Medical School: Sang Hyun Kwak; Samsung Medical Center, Sungkyunkwan University School of Medicine: Gee Young Suh; Asan Medical Center, University of Ulsan College of Medicine: Chae-Man Lim
Taiwan: Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine: Mei-Lien Tu; Kaohsiung Armed Forces General Hospital: Shao-Ting Chou; Yuan’s General Hospital: Yu-Feng Liang; E-DA Hospital, Kaohsiung County: Yu-Feng Wei; Chi-Mei Medical Center, Tainan: Kuo-Chen Cheng
Thailand: Chulalongkorn Memorial Hospital: Phornlert Chatrkaw; Siriraj Hospital: Chairat Permpikul; Maharaj Chiangmai Hospital: Chaicharn Pothirat
Vietnam: Bachmai Hospital: Dang Tuan Nguyen; General Danang Hospital: Duc Nhan Le
Author information
Authors and Affiliations
Consortia
Corresponding author
Ethics declarations
Conflicts of interest
The authors declare that they have no conflict of interest.
Additional information
Take-home message: As opposed to high-income countries and regions, physicians in low-middle-income Asian countries and regions often make end-of-life care decisions predominantly based on perceived families’ demands and financial constraints rather than patients’ wishes and medical conditions, while resources are often spent on prolonging deaths rather than saving lives. A more coherent, humane, cost-effective and yet culturally sensitive approach to dying patients is needed in these countries and regions.
On behalf of the ACME Study Investigators and the Asian Critical Care Clinical Trials Group.
The members of the ACME Study Investigators and the Asian Critical Care Clinical Trials Group are listed under Acknowledgments.
An erratum to this article is available at http://dx.doi.org/10.1007/s00134-016-4365-9.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Phua, J., Joynt, G.M., Nishimura, M. et al. Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions. Intensive Care Med 42, 1118–1127 (2016). https://doi.org/10.1007/s00134-016-4347-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00134-016-4347-y