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Intensive Care Medicine

, Volume 42, Issue 7, pp 1118–1127 | Cite as

Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions

  • Jason Phua
  • Gavin M. Joynt
  • Masaji Nishimura
  • Yiyun Deng
  • Sheila Nainan Myatra
  • Yiong Huak Chan
  • Nguyen Gia Binh
  • Cheng Cheng Tan
  • Mohammad Omar Faruq
  • Yaseen M. Arabi
  • Bambang Wahjuprajitno
  • Shih-Feng Liu
  • Seyed Mohammad Reza Hashemian
  • Waqar Kashif
  • Dusit Staworn
  • Jose Emmanuel Palo
  • Younsuck Koh
  • ACME Study Investigators and the Asian Critical Care Clinical Trials Group
Original

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.

Keywords

End-of-life care Critical care Physicians Families Legal Economics 

Notes

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

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflict of interest.

Supplementary material

134_2016_4347_MOESM1_ESM.docx (19 kb)
Supplementary material 1 (DOCX 19 kb)
134_2016_4347_MOESM2_ESM.docx (25 kb)
Supplementary material 2 (DOCX 25 kb)

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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2016

Authors and Affiliations

  • Jason Phua
    • 1
  • Gavin M. Joynt
    • 2
  • Masaji Nishimura
    • 3
  • Yiyun Deng
    • 4
  • Sheila Nainan Myatra
    • 5
  • Yiong Huak Chan
    • 6
  • Nguyen Gia Binh
    • 7
  • Cheng Cheng Tan
    • 8
  • Mohammad Omar Faruq
    • 9
  • Yaseen M. Arabi
    • 10
  • Bambang Wahjuprajitno
    • 11
  • Shih-Feng Liu
    • 12
    • 13
  • Seyed Mohammad Reza Hashemian
    • 14
  • Waqar Kashif
    • 15
  • Dusit Staworn
    • 16
  • Jose Emmanuel Palo
    • 17
  • Younsuck Koh
    • 18
  • ACME Study Investigators and the Asian Critical Care Clinical Trials Group
    • 19
  1. 1.Division of Respiratory and Critical Care MedicineUniversity Medicine Cluster, National University Hospital, National University Health SystemSingaporeSingapore
  2. 2.Department of Anaesthesia and Intensive CareThe Chinese University of Hong Kong, Prince of Wales HospitalHong KongChina
  3. 3.Emergency and Critical Care MedicineUniversity of Tokushima Graduate SchoolTokushimaJapan
  4. 4.Intensive Care UnitWest China Hospital of Sichuan UniversityChengduChina
  5. 5.Department of Anaesthesia, Critical Care and PainTata Memorial HospitalMumbaiIndia
  6. 6.Biostatistics Unit, Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
  7. 7.Intensive Care DepartmentBach Mai HospitalHanoiVietnam
  8. 8.Department of Anaesthesia and Intensive CareSultanah Aminah HospitalJohor BahruMalaysia
  9. 9.Department of Critical Care MedicineBIRDEM General Hospital, Ibrahim Medical CollegeDhakaBangladesh
  10. 10.King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research CenterRiyadhSaudi Arabia
  11. 11.Department of Anesthesiology and Reanimation, Faculty of MedicineUniversity of Airlangga, Dr. Soetomo General HospitalSurabayaIndonesia
  12. 12.Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiungTaiwan
  13. 13.Department of Respiratory TherapyKaohsiung Chang Gung Memorial Hospital and Chang Gung University College of MedicineKaohsiungTaiwan
  14. 14.Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Masih Daneshvari HospitalShahid Beheshti University of Medical SciencesTehranIran
  15. 15.Section of Nephrology, Pulmonary and Critical Care, Department of MedicineAga Khan University and HospitalKarachiPakistan
  16. 16.Phramongkutklao HospitalBangkokThailand
  17. 17.The Medical CityPasig CityPhilippines
  18. 18.Department of Pulmonary and Critical Care MedicineAsan Medical Center, University of Ulsan College of MedicineSeoulSouth Korea
  19. 19.SingaporeSingapore

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