[End-of life decisions in intensive care units. Influence of patient wishes on therapeutic decision making]

Abstract

Background: Among the ethical principles in medicine, respect for patient autonomy has gained the highest revaluation in recent decades. In Germany this was fostered by new legal regulations which came into effect in 2009 and clarified issues regarding end-of-life (EOL) decisions. In this study the influence of direct or mediated wishes of patient wills on EOL decisions in a medical intensive care unit (ICU) were investigated.

Methods: A retrospective analysis of all patients who died in the years 2009-2010 while being treated in the medical ICU of a large German university hospital was carried out.

Results: During the observation period 3,401 patients were treated in the ICU of whom 19 % (n=658) died in hospital. Of the 658 patients who died 126 (19 %) had received unlimited therapy, life support was withheld in 241 patients (37 %) and life support was withdrawn in 245 patients (37 %). In 46 patients (7 %) palliative care was instituted from the beginning of the ICU stay. In 104 cases (16 %) the patients themselves made the EOL decision and in 78 cases (12 %) an advance directive was given. A legal healthcare proxy was designated in 8 %. In 541 cases (82 %) the relatives were involved in the EOL decisions. No serious or unsolvable conflicts with relatives were experienced. Involvement of a court of law was not necessary in any of the cases.

Conclusions: In a high percentage of the patients (81 %) who died during the course of intensive care treatment EOL policies were in place. The patients or their relatives were almost always involved in the decision making process. The current German law is in concordance with the established EOL practice in this intensive care unit.