Life sustaining treatment decisions in Portuguese intensive care units

Objectives

To evaluate current views and practice of Portuguese intensive care physicians regarding end-of-life decisions, namely 'do not resuscitate' (DNR) orders and withhold/withdraw treatment decisions.

Design and methods

An individual questionnaire was sent to full-time intensive care physicians working in the intensive care units (ICUs) registered in the Portuguese Intensive Care Society. High dependency and specialised units (like burns and coronary care units) were excluded. A comparison was done between religious and non-religious, more and less experienced (>10 years or ≤ 10 years of practice in ICU), younger and older (< 45 or ≥ 45 years), female and male doctors, as well as between doctors working in small and larger (≤ 8 beds or > 8 beds) ICUs. Chi-square test was used to compare different groups.

Results

A total of 250 questionnaires were sent in October 2001 and 140 returned (56%) until the end of November. Physicians from 68% of the country ICUs participated in the study. The vast majority of physicians answered that DNR orders (100%) and withhold and withdraw treatment decisions (98.6%) are made in their units. Regarding these decisions approximately three-quarters of the physicians answered that they are made by the medical group alone and this answer is more prevalent in the group of religious and less experienced doctors (P < 0.05). Thirteen to sixteen per cent of the physicians, mainly the more experienced (P < 0.05) answered that the nurses are involved in the decision. Eleven to sixteen per cent, mainly the non-religious doctors (P < 0.05), involve the patient or relatives in the decision. When asked about who they think these decisions should involve: 45–50% think that the patient or relatives should participate – mainly the non-religious (P < 0.05); 27–36% think that nurses should be involved – mainly the more experienced doctors (P < 0.05); 43–48% of the doctors feel that these decisions should be made by the medical group alone – mainly the religious and less experienced. Regarding documentation of DNR orders only 2.1% answered that their unit uses a specific document and 49.3% said that it is just transmitted orally to the working group. The same applies for withhold and withdraw treatment decisions, with 43.5% and 38.4% of the physicians answering that they are just transmitted orally. Probability of survival to the current episode and the patient wishes were the most important factors pointed out by the physicians that influence refusal of ICU admission, DNR orders and withhold or withdraw treatment decisions. Only 37.9% of the physicians said that a DNR order precedes a withdraw treatment decision. Eighty-two per cent continue or start comfort measures like morphine infusion, after a withdraw treatment decision is made.

Conclusions

End-of-life decisions are a current practice in the inquired Portuguese ICUs. These decisions are taken by the medical group alone in most ICUs, although there is a will to involve the nurses and the patient or relatives in the process. The experience and religious beliefs of the respondents influence the way these decisions are taken (but not age, sex or the ICU size). The practice of writing down these decisions is not done on a regular basis and needs to be improved.