[Parte III. Ethical and juridical aspects in end-stage chronic organ failures. A position paper on a shared care planning]. / Parte III. Aspetti etici e giuridici nelle insufficienze croniche d'organo "end-stage". Documento di consenso per una pianificazione condivisa delle scelte di cura.

The specific target of an experts panel was to assess in terms of law and ethics the compliance of a new specific decision making algorithm described in the position paper proposed by the Gruppo di Lavoro Insufficienze Croniche d'Organo, with the main goal of the position paper consisting in the shared care planning process. The following specific aspects were assessed by the experts: a) the impact on case law and statute law of a new clinical pathway shared by scientific societies in light of good clinical practice and scientific evidence; b) the relevance of all tools useful to identify the appropriateness of care pathways, recognizing responsibilities and decision-making skills related to the end of life choices made by all stakeholders involved (healthcare professionals, patients and their beloved ones); c) the consistency of the healthcare professionals duties proposed in the position paper with the Italian legal order; d) the opportunity to take into account the role of all healthcare providers involved in care relationship; e) the consistency of the definition of patient rights at the end of life as proposed in the position paper with the Italian legal order and the relevance in this context of simultaneous palliative care; f) the relevance of shared care planning and its consistency with the proposed operative tools; g) the relevance of the conscientious objection issue and the compliance of management tools proposed in the position paper with the results of ethical and legal considerations; h) considerations about available resources allocation.

End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units.

PURPOSE: To appraise the end-of-life decision-making in several intensive care units (ICUs) and to evaluate the association between the average inclination to limit treatment and overall survival at ICU level. DESIGN: Prospective, multicenter, observational study, lasting 12 months. SETTING: Eighty-four Italian, adult ICUs. PATIENTS: Consecutive patients (3,793) who died in ICU or were discharged in terminal condition, in 2005. MEASUREMENTS: Data collection included patient description, treatment limitation and decision-makers, involvement of patients and relatives in the decision, and organ donation. A logistic regression model was used to identify predictors of treatment limitation and develop a measure of the inclination to limit treatment for each ICU. This was compared with the standardized mortality ratio, an index of the overall performance of the unit. RESULTS: Treatment limitation preceded 62% of deaths. In 25% of cases, nurses were involved in the decision. Half the limitations were do-not-resuscitate orders, with the remaining half almost equally split between withholding and withdrawing treatment. Units less inclined to limit treatments (odds ratio <0.77) showed higher overall standardized mortality ratio (1.08; 95% confidence interval: 1.04-1.12). LIMITATIONS: The voluntary nature of participation, with self-selected ICUs from a self-selected independent network. CONCLUSIONS: Treatment limitation is common in ICU and still principally a physician's responsibility. Units with below-average inclination to limit treatments have worse performance in terms of overall mortality, showing that limitation is not against the patient's interests. On the contrary, the inclination to limit treatments at the end of life can be taken as an indication of quality in the unit.