End-of-life decisions in intensive care units: attitudes of physicians in an Italian urban setting
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To assess the attitudes of physicians in Milan, Italy, intensive care units (ICUs) regarding end-of-life decisions.
Anonymous self-administered questionnaire.
All 20 ICUs in Milan.
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.
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.
KeywordsIntensive care Ethics Life-sustaining treatments Withdrawing treatment Withholding treatment End-of-life decisions
Acknowledgements. This study was partly supported by the Catholic University of Milan. It was presented in part at the Third Congress of Italian Society for Bioethics and Ethical Committees, November, 2002. We thank all the physicians who completed the questionnaire; G. Casazza (Chair of Statistics, Department of Clinical Sciences "L. Sacco", University of Milan) and C. Lanzetti (Department of Sociology, Catholic University of Milan) for the statistical analysis; E. Colombetti (Centre for Bioethics, Catholic University of Milan) for helpful criticism; and D. Ward for the translation.
Table 6. Results of multiple logistic regression for selected reported practices (PDF 18 KB)
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