End-of-life care in the intensive care unit: the Irish Ethicus data.

ABSTRACT

OBJECTIVE: To study the frequency, rationale and process for withholding (WH) and withdrawing (WD) life-sustaining therapies in intensive care patients in Ireland. DESIGN: Prospective, observational study, comprising a subset of the European Ethicus Study. SETTING AND PARTICIPANTS: 122 patients who died or who had life-sustaining therapies limited in the ICU of a university hospital, 1 September 1999 to 30 June 2000. OUTCOME MEASURES AND RESULTS: An end-of-life (EOL) treatment decision was made for 85/122 patients (69%). Forty-five (36%) had therapy withheld, 40 (33%) had it withdrawn, 26 (21%) had unsuccessful cardiopulmonary resuscitation, and 11 (10%) suffered brain death. The median time from ICU admission to death was 4.0 days for WH patients and 2.9 days for WD patients (range, 10 minutes to 123 days). The discussion to limit therapy was initiated by the ICU doctor in 50 cases (59%), and involved families in 66 cases (78%). Families initiated 9% of EOL discussions. Nursing staff were involved in 98% of decisions. No patients were mentally competent, but their wishes were known in 28% of cases. The primary reason for limiting life-sustaining therapy was that the patient was unresponsive to maximum therapy (68% of patients). An EOL decision was made every 55 hours during "office hours" and every 120 hours during "on-call" working hours. Withholding was more frequent than withdrawing during "on call" periods. DISCUSSION: The frequency of withdrawal or withholding of therapy in this Irish ICU is in line with current international practice. The time to EOL decision-making is variable and relatively short compared with that in the United States, but similar to that in Europe. Clinicians are the primary initiators of the EOL decision in Ireland, with little patient involvement. Family members are more likely to initiate an EOL decision than in Europe. EOL decisions were usually made during "routine" working hours after significant consultation with all groups.