End-of-life care in the critically ill: a description of knowledge, attitudes and practices of physicians and nurses from Karachi, Pakistan

Introduction

As the numbers of people admitted to ICUs are increasing, physicians are faced with obligations beyond attempting to reverse illness and include providing quality end-of-life care. Barriers to this include inadequate understanding of the dying patient and withdrawal or limitation of care. The objectives of this study were to document the comprehensions of physicians and nurses dealing with these situations.

Methods

We carried out a cross-sectional survey of clinicians working at three hospitals in Karachi (one private, university hospital, one mixed public and private, tertiary care hospital and one large government-funded hospital). A 13-question instrument was developed to assess recognition of end-of-life in the ICU, knowledge of commonly used terms to describe limitations of care, and attitudes and practices towards withdrawal and limitation of life-support measures and organ harvest for transplantation. After measuring the frequencies for presentation of the data, differences between the three respondent subgroups were compared using a chi-square analysis. Fisher's exact test was used where the individual cell count was <5. A one-way analysis of variance was used to compare differences in age and years of practice. A two-sided P value of <0.05 was considered statistically significant.

Results

A total of 137 physicians and critical care nurses completed the survey. The average age was 34 years and 58% were males. 'Brain death' was defined as an 'irreversible cessation of brainstem function' by 85% of respondents; 77% relying on clinical examination, 49.6% consulting neurophysicians and 28.3% ordering further testing to confirm the diagnosis. Withdrawal of life support is practiced by 83.2%; most frequently in the setting of absent brainstem and cortical functioning (74.3%), followed by acute, progressive multiorgan failure (39.8%). Physicians are more likely (P value 0.000) to withdraw mechanical ventilation, compared with nurses who would withdraw vasopressors (P value 0.006). The primary physician is the most frequent caregiver (60.2%) to start a discussion on withdrawal of life support, with 72.6% respondents consulting the Hospital Ethics Committee. Only 13.3% respondents never withdraw life support; 28.3% considered it their responsibility to 'sustain life at all costs' and only 8% gave religious beliefs as a reason. Only 56.6% favored organ harvest for transplantation from cadavers, while 64.6% supported harvest from brain dead individuals. Nurses were significantly more likely to support organ harvest for transplant from heart-beating, brain dead individuals (P value 0.025) than cadavers (P value 0.000).

Conclusion

There are deficiencies and disparities in the understandings of physicians and nurses on the recognition and management of end-of-life in the ICU.