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Background Little is known about the attitudes and practices of intensivists working in Lebanon regarding withholding and withdrawing life-sustaining treatments (LSTs). The objectives of the study were to assess the points of view and practices of intensivists in Lebanon along with the opinions of medical, legal and religious leaders regarding withholding withdrawal of life-sustaining treatments in Lebanese intensive care units (ICU). Methods A web-based survey was conducted among intensivists working in Lebanese adult ICUs. Interviews were also done with Lebanese medical, legal and religious leaders. Results Of the 229 survey recipients, 83 intensivists completed it, i.e. a response rate of (36.3%). Most respondents were between 30 and 49 years old (72%), Catholic Christians (60%), anesthesiologists (63%), working in Beirut (47%). Ninety-two percent of them were familiar with the withholding and withdrawal concepts and 80% applied them. Poor prognosis of the acute and chronic disease and futile therapy were the main reasons to consider withholding and withdrawal of treatments. Ninety-five percent of intensivists agreed with the “Principle of Double Effect” (i.e. adding analgesia and or sedation to patients after the withholding/withdrawal decisions in order to prevent their suffering and allow their comfort, even though it might hasten the dying process). The main withheld therapies were vasopressors, respiratory assistance and CPR. Most of the respondents reported the decision was often to always multidisciplinary (92%), involving the family (68%), and the patient (65%), or his advance directives (77%) or his surrogate (81%) and the nurses (78%). The interviewees agreed there was a law governing withholding and withdrawal decisions/practices in Lebanon. Christians and Muslim Sunni leaders declared accepting those practices (withholding or withdrawing LSTs from patients when appropriate). Conclusion Withholding and withdrawal of LSTs in the ICU are known concepts among intensivists working in Lebanon and are being practiced. Our results could be used to inform and optimize therapeutic limitation in ICUs in the country.

This study presents, for the first time, empirical data on practices regarding bioethical decision-making in treatment of preterm and ill newborns in Greece. The aim of the study was to: a) record self-reported practices and involvement of Greek physicians in decisions of withholding and withdrawing neonatal intensive care, and b) explore the implication of cultural, ethical, and professional parameters in decision-making. Methods: 71 physicians, employed fulltime in all public Neonatal Intensive Care Units (NICUs) (n = 17) in Greece, completed an anonymous questionnaire between May 2009 and May 2011. Results: One-third of the physicians in our sample admitted that they have, at least once in the past, decided the limitation of intensive care of a newborn close to death (37.7%) and/or a newborn with unfavorable neurological prognosis (30.8%). The higher the physicians&rsquo, support towards the value of quality of human life, the more probable it was that they had taken a decision to withhold or withdraw neonatal intensive care (p &lt, 0.05). Conclusions: Our research shows that Greek NICU physicians report considerably lower levels of ethical decision-making regarding preterm and ill newborns compared to their counterparts in other European countries. Clinical practices and attitudes towards ethical decision-making appear to be influenced mainly by the Greek physicians&rsquo, values.

Background Prolonged support of organ functions without therapeutic benefit represents a serious problem of therapy in intensive care units (ICUs). This kind of treatment, called "futile therapy", prolongs the process of dying and should be avoided. In Poland, the guidelines and protocol defining the best clinical practice for the avoidance of futile therapy in ICUs was published in 2014. The aim of study was to analyse the protocols concerning futile therapy in the general ICU in the University Hospital in Wroclaw, Poland during the years 2015-2018. Methods The content of protocols was analysed. The protocols contained information on clinical problems, ethical and social aspects, data on communication with relatives, and therapeutic procedures regarded as futile and consequently withheld or withdrawn. Results During the study 1660 patients were treated in the ICU, of whom 557 patients died. Protocols regarding futile therapy were analysed in 146 patients. The diagnosis before starting the protocol was multiorgan failure (56%), permanent CNS injury (39%), respiratory failure (3%), and circulatory failure (2%). The withholding of therapeutic procedures was preferred, and the cases of withdrawal were rare. All patients with protocols died during hospital stay, 81.5% of them in the ICU. Conclusions The protocols concerning futile therapy were instituted in 1 in 10 patients treated in the ICU in Wroclaw, which comprised was nearly one-fifth of all ICU deaths. The withholding of futile therapeutic procedures was preferred in comparison to withdrawing. Communication with relatives was essential to the process of avoiding futile therapy.

ResumenLos cuidados intensivos pediátricos son una especialidad nueva, con importantes avances tecnológicos que pueden prolongar el proceso de morir. Uno de los problemas bioéticos frecuentes es la limitación del esfuerzo terapéutico, que es la adecuación y/o proporcionalidad del tratamiento tratando de evitar obstinación y futilidad.ObjetivoConocer la experiencia de médicos que trabajan en unidades de cuidado intensivo (UCIP) ante decisiones ético-clínicas.Sujetos y métodoEstudio observacional, descriptivo y transversal, aplicando una encuesta anónima a médicos de UCIP, solicitando datos sobre problemas éticos que se generan en la atención al niño crítico y su procedimiento de resolución. Aprobado por el Comité de Ética de la Investigación de la Facultad de Medicina de la Universidad del Desarrollo-Clínica Alemana.ResultadosRespondieron 126 médicos de 34 UCIP de Chile. El 98,41% ha tomado decisiones de limitación terapéutica. El tipo de limitación más frecuente mencionado fue la orden de no reanimar (n=119), seguido por la no instauración de medicamentos (n=113), limitación de ingreso a UCIP (n=81), siendo la menos mencionada la retirada de tratamientos (n=81). El 34,13% consideró que existían diferencias éticas entre no instaurar o retirar un determinado tratamiento.ConclusionesLos dilemas ético-clínicos son comunes en la UCIP, siendo frecuentes las decisiones de limitación terapéutica. Muchos médicos reconocen no poseer conocimientos en ética clínica y necesitar formación continua en bioética.AbstractPaediatric intensive care is a relatively new specialty, with significant technological advances that lead to the prolongation of the dying process. One of the most common bioethical problems is limitation of treatment, which is the adequacy and/or proportionality treatment, trying to avoid obstinacy and futility.ObjectiveTo determine the experience of physicians working in Paediatric Intensive Care Units (PICU) when faced with bioethical decisions.Subjects and methodAn observational, descriptive and cross-sectional study was conducted using an anonymous questionnaire sent to physicians working in PICU. The data requested was related to potential ethical problems generated in the care of the critical child, and the procedure for their resolution. The study was approved by the Ethics Research Committee of the Faculty of Medicine UDD CAS.ResultsA total of 126 completed questionnaires were received from physicians working in 34 PICU in Chile. Almost all (98.41%) of them acknowledged having taken therapeutic limitation decisions (TLD). The most common type of TLD mentioned was the Do Not Resuscitate order (n=119), followed by the establishment of no medications (n=113), limited admission to PICU (n=81), with the withdrawal of treatment being the least mentioned (n=81). Around one-third (34.13%) felt that there were no ethical difference between introducing or removing certain treatments.ConclusionsBioethical dilemmas are common in the PICU, with therapeutic limitation decisions being frequent. Many recognise not having expertise in clinical ethics, and they need continuing education in bioethics.

Resumen Los cuidados intensivos pediátricos son una especialidad nueva, con importantes avances tecnológicos que pueden prolongar el proceso de morir. Uno de los problemas bioéticos frecuentes es la limitación del esfuerzo terapéutico, que es la adecuación y/o proporcionalidad del tratamiento tratando de evitar obstinación y futilidad. Objetivo Conocer la experiencia de médicos que trabajan en unidades de cuidado intensivo (UCIP) ante decisiones ético-clínicas. Sujetos y método Estudio observacional, descriptivo y transversal, aplicando una encuesta anónima a médicos de UCIP, solicitando datos sobre problemas éticos que se generan en la atención al niño crítico y su procedimiento de resolución. Aprobado por el Comité de Ética de la Investigación de la Facultad de Medicina de la Universidad del Desarrollo-Clínica Alemana. Resultados Respondieron 126 médicos de 34 UCIP de Chile. El 98,41% ha tomado decisiones de limitación terapéutica. El tipo de limitación más frecuente mencionado fue la orden de no reanimar (n = 119), seguido por la no instauración de medicamentos (n = 113), limitación de ingreso a UCIP (n = 81), siendo la menos mencionada la retirada de tratamientos (n = 81). El 34,13% consideró que existían diferencias éticas entre no instaurar o retirar un determinado tratamiento. Conclusiones Los dilemas ético-clínicos son comunes en la UCIP, siendo frecuentes las decisiones de limitación terapéutica. Muchos médicos reconocen no poseer conocimientos en ética clínica y necesitar formación continua en bioética. Abstract Paediatric intensive care is a relatively new specialty, with significant technological advances that lead to the prolongation of the dying process. One of the most common bioethical problems is limitation of treatment, which is the adequacy and/or proportionality treatment, trying to avoid obstinacy and futility. Objective To determine the experience of physicians working in Paediatric Intensive Care Units (PICU) when faced with bioethical decisions. Subjects and method An observational, descriptive and cross-sectional study was conducted using an anonymous questionnaire sent to physicians working in PICU. The data requested was related to potential ethical problems generated in the care of the critical child, and the procedure for their resolution. The study was approved by the Ethics Research Committee of the Faculty of Medicine UDD CAS. Results A total of 126 completed questionnaires were received from physicians working in 34 PICU in Chile. Almost all (98.41%) of them acknowledged having taken therapeutic limitation decisions (TLD). The most common type of TLD mentioned was the Do Not Resuscitate order (n = 119), followed by the establishment of no medications (n = 113), limited admission to PICU (n = 81), with the withdrawal of treatment being the least mentioned (n = 81). Around one-third (34.13%) felt that there were no ethical difference between introducing or removing certain treatments. Conclusions Bioethical dilemmas are common in the PICU, with therapeutic limitation decisions being frequent. Many recognise not having expertise in clinical ethics, and they need continuing education in bioethics.

This study investigated how intensivists make decisions regarding withholding and withdrawing treatment for patients at the end of their lives. This involved completing in-depth interviews from two sites of the South of England, United Kingdom by twelve intensivists. The data collected by these intensivists were analysed using thematic analysis. This resulted in the identification of three themes: intensivists’ role, treatment effectiveness, and patients’ best interest. Transcending these were two overarching themes relating to the balance between quantity and quality of life, and the intensivists’ sense of responsibility versus burden. The results are considered in terms of making sense of death and the role of beliefs in the decision-making process.

International audience; Since the implementation of two French laws in 2002 and 2005 and the implementation of guidelines about End-of-Life (EoL) decisions, few studies concerning EoL practices in French intensive care units (ICUs) have been reported. This study was aimed at assessing compliance with recommendations and current legislation concerning EoL decisions. Prospective observational study based on 1-day audit conducted from January to May 2009 in 66 southern French ICUs. Six hundred and twenty-five patients were included (median age: 63 [52-76] years, median SAPS II: 46 [34-58]). The written designation of a surrogate decision-maker was reported for 87 (15%) patients. Advance directives were completed for only 4% of patients. The EoL decision-making process consisted in a multidisciplinary approach for 99 (47%) patients and was recorded in the medical chart for 63 (64%) cases. Families were informed about medical decisions in 58% of cases. This proportion was higher (87%) if a decision to forego life-sustaining therapy was made. EoL decisions consisted of withholding treatments for 72 (94%) patients and withdrawal of treatments for 5 (6%) patients. In the multivariate stepwise logistic regression, four variables were independently associated with a decision to forego life support: preexisting dependence on others (P

End-of-life decisions are made daily in intensive care units worldwide. There are numerous factors affecting these decisions, including geographical location as well as religion and attitudes of caregivers, patients, and families. There is a spectrum of end-of-life care options from full continued care, withholding treatment, withdrawing treatment, and active life-ending procedures.

V ANGICKÉM JAZYCE THE FUTILE TREATMENT IN THE INTENSIVE CARE The theoretical part is define the concept of the futile treatment, analyze its legal and ethical context, especially within nursing and medical interventions, categorize the treatment and summarize the procedure of making decisions of changing the treatment in the Czech Republic. The purpose of the theoretical part is mapping the situations when the intensive care is pointless and how to proceed in the situations like these. The practical part will process a qualitative research by a form of personal interviews with several representatives of the professional public. The purpose of the practical part is to describe their personal experiences with this issue and to know their opinions of the situations when the futile retreatment is under way and how to categorize a treatment correctly. These interviews isprocessed by a form of the final discussion then. KEY WORDS: futile retreatment, intensive care, categorization, life quality, withdrawing, withholding, interview, euthanasia

End-of-life decisions represent one of the most complex and challenging issues in pediatric intensive care. These recommendations aim to offer Italian pediatric intensive care unit (PICU) teams a framework for the end-of-life decision-making process. The paper proposes a process based on the principle that the use of a diagnostic or therapeutic tool must comply with a 'criterion of proportionality'. Appropriately informed parents, as natural interpreters and advocates of the best interests of their child, can contribute in assessing the burdensomeness of the treatment and determining its proportionality. The decision to limit, withdraw or withhold life-sustaining treatments considered disproportionate represents a clinically and ethically correct choice. This decision should be made (a) collectively by PICU team and the other caregivers, (b) with the explicit involvement of parents, and (c) noting in the patient's clinical record the decisions taken and the reasons behind them. The withdrawing or withholding of life support can never entail the abandonment of the patient nor the withdrawal of any therapy aimed at treating any form of suffering. No action aimed at deliberately hastening the death of the patient is ever acceptable. These recommendations advocate a decision as far as possible shared by patient (whenever feasible), parents and caregivers. Ensuring that all involved are kept fully informed and that there is open and timely communication between them is the key to achieving this. It is the physician in charge of the patient's care and the head of the unit who bear the main responsibility for the final decision.

Background: Limitations of life-support interventions, by either withholding or withdrawing support, are integrated parts of intensive care unit (ICU) activities and are ethically acceptable. The end-of-life legal aspects and practices in United Arab Emirates ICUs are rarely mentioned in the medical literature. The objective of this study was to examine the current practice of limiting futile life-sustaining therapies in our ICU, modalities for implementing of these decisions, and documentations in dying critically ill patients. Materials and Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected. Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected. Results: The electronic medical records of 67 patients were reviewed. The commonest method of limiting therapy was no escalation 53.6%. Interventions were withheld in 41.5%. “Do not resuscitate” order was documented in only 16.3%. The commonest method of documenting limitation of therapy was discussion with the family and documenting the prognosis and futility of additional therapy (73.3%). Patients who died early (48 hrs) of ICU admission received terminal cardiopulmonary resuscitation more frequently (P < 0.007), had less frequent prognosis documentation (P < 0.009), and had more vasopressors administered (P < 0.006). Conclusion: Withholding therapy after discussion with the family was the preferred mode of limiting therapy in a dying patient.