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Making decisions to withhold or withdraw treatment in the paediatric intensive care setting can be complex, emotive and morally challenging. The process draws on the expertise and experience of both the families and the medical teams, their understanding of the needs and (where possible) choices of the child, and a balance of trust between all parties to want to achieve the right outcome. It is important that all healthcare professionals caring for children, particularly those living with potentially life-limiting or life-threatening conditions, are aware of the processes involved so they can support patients and families with confidence and sensitivity. This paper explores the basic aspects of withholding and withdrawing interventions in the PICU with the aim of demonstrating the situations in which these decisions might be necessary. It explains the frameworks and considerations guiding the decision-making process and describes the practicalities of providing ongoing care through collaboration with hospital and community services. [ABSTRACT FROM AUTHOR]

Abstract Background Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies. Methods Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems. Results This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries. Conclusions This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field.

Background: Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies. Methods: Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems. Results: This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries. Conclusions: This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field. [ABSTRACT FROM AUTHOR]

Abstract Background Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU. Methods This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST. Results The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables. Conclusions Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017.

The number of diagnoses and the number of persons having diagnoses have increased substantially, and studies indicate that diagnoses are given or upheld even if they are unwarranted, that is, that they do not satisfy professionally accepted diagnostic criteria. In this article, the authors investigate the ethics of withholding and withdrawing unwarranted diagnoses. First, they investigate ethical aspects that make it difficult to withhold and to withdraw such diagnoses. Second, they scrutinize whether there are psychological factors, both in persons/patients and healthcare professionals, making it difficult to withdraw and withhold unwarranted diagnoses. Lastly, they use recent elements of the withholding-versus-withdrawing treatment debate in medical ethics to investigate whether there are any differences between withholding and withdrawing treatment and withdrawing and withholding unwarranted diagnoses. The authors conclude that it is crucial to acknowledge and address all these issues to reduce and avoid unwarranted diagnoses. [ABSTRACT FROM AUTHOR]

Background: Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU. Methods: This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST. Results: The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables. Conclusions: Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017. [ABSTRACT FROM AUTHOR]

Abstract Background There has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying. Methods A cross-sectional study was conducted on a three-stage random sample of adult citizens of the Republic of Croatia, stratified by regions, counties, and locations within those counties (N = 1203). In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis (component model, varimax rotation and GK dimensionality reduction criterion), correlation analysis (Bivariate correlation, Pearson’s coefficient) and multiple regression analysis for data analysis. Results 38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person’s autonomous decisions regarding end-of-life procedures. Conclusions The study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people’s views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia.

Life expectancy is rising worldwide and increasing numbers of elderly patients are being admitted to the intensive care unit (ICU). Because ageing is associated with changes in organ function, increased frailty, reduced activities of daily living, reduced mobility, and reduced cognition, elderly patients represent a particular subgroup of ICU patients. Ethical decisions related to the appropriateness of intensive care and/or life‐sustaining interventions, the withdrawing and withholding of life support, and terminal sedation are more frequent in these patients and will be discussed in this review. Such decisions must be tailored to the individual to take into consideration personal beliefs and wishes. [ABSTRACT FROM AUTHOR]

Background: There has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying.Methods: A cross-sectional study was conducted on a three-stage random sample of adult citizens of the Republic of Croatia, stratified by regions, counties, and locations within those counties (N = 1203). In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis (component model, varimax rotation and GK dimensionality reduction criterion), correlation analysis (Bivariate correlation, Pearson's coefficient) and multiple regression analysis for data analysis.Results: 38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person's autonomous decisions regarding end-of-life procedures.Conclusions: The study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people's views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia. [ABSTRACT FROM AUTHOR]

As options for advanced cardiopulmonary support proliferate, the use of mechanical circulatory support, such as left ventricular assist device as destination therapy (LVAD-DT), is becoming increasingly commonplace. In the current case, a patient was hospitalized for complications related to his LVAD-DT requests ?full code? status, despite a clinician's warning that performing chest compressions may damage the LVAD device or vascular structures leading to poor outcome. This discussion explores the ethical and legal considerations regarding a patient request for cardiopulmonary resuscitation when limited options for survival or further treatment are available.

Many countries have adopted new triage recommendations for use in the event that intensive care beds become scarce during the COVID‐19 pandemic. In addition to establishing the exact criteria regarding whether treatment for a newly arriving patient shows a sufficient likelihood of success, it is also necessary to ask whether patients already undergoing treatment whose prospects are low should be moved into palliative care if new patients with better prospects arrive. This question has led to divergent ethical guidelines. This paper explores the distinction between withholding and withdrawing medical treatment during times of scarcity. As a first central point, the paper argues that a revival of the ethical distinction between doing and allowing would have a revisionary impact on cases of voluntary treatment withdrawal. A second systematic focus lies in the concern that withdrawal due to scarcity might be considered a physical transgression and therefore more problematic than not treating someone in the first place. In light of the persistent disagreement, especially concerning the second issue, the paper concludes with two pragmatic proposals for how to handle the ethical uncertainty: (1) triage protocols should explicitly require that intensive care attempts are designed as time‐limited trials based on specified treatment goals, and this intent should be documented very clearly at the beginning of each treatment; and (2) lower survival prospects can be accepted for treatments that have already begun, compared with the respective triage rules for the initial access of patients to intensive care. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether parent-initiated or doctor-initiated decisions about limiting life-sustaining treatment (LST) in neonatal care has consequences for how possible courses of action are presented.Method: Formal conversations (n = 27) between doctors and parents of critically ill babies from two level 3 neonatal intensive care units were audio or video recorded. Sequences of talk where decisions about limiting LST were presented were analysed using Conversation Analysis and coded using a Conversation Analytic informed coding framework. Relationships between codes were analysed using Fisher's exact test.Results: When parents initiated the decision point, doctors subsequently tended to refer to or list available options. When doctors initiated, they tended to use 'recommendations' or 'single-option' choice (conditional) formats (p=0.017) that did not include multiple treatment options. Parent initiations overwhelmingly concerned withdrawal, as opposed to withholding of LST (p=0.030).Conclusion: Aligning parents to the trajectory of the news about their baby's poor condition may influence how the doctor subsequently presents the decision to limit LST, and thereby the extent to which parents are invited to participate in shared decision-making.Practice Implications: Explicitly proposing treatment options may provide parents with opportunities to be involved in decisions for their critically ill babies, thereby fostering shared decision-making. [ABSTRACT FROM AUTHOR]

In healthcare priority settings, early access to treatment before reimbursement decisions gives rise to problems of whether negative decisions for cost‐effectiveness reasons should result in withdrawing treatment, already accessed by patients. Among professionals there seems to be a strong attitude to distinguish between withdrawing and withholding treatment, viewing the former as ethically worse. In this article the distinction between withdrawing and withholding treatment for reasons of cost effectiveness is explored by analysing the doing/allowing distinction, different theories of justice, consequentialist and virtue perspectives. The authors do not find any strong reasons for an intrinsic difference, but do find some reasons for a consequentialist difference, given present attitudes. However, overall, such a difference does not, all things considered, provide a convincing reason against withdrawal, given the greater consequentialist gain of using cost‐effective treatment. As a result, patients should be properly informed when given early access to treatment, that such treatment can be later withdrawn following a negative reimbursement decision. [ABSTRACT FROM AUTHOR]

With few exceptions, the literature on withdrawing and withholding life-saving treatment considers the bare fact of withdrawing or withholding to lack any ethical significance. If anything, the professional guidelines on this matter are even more uniform. However, while no small degree of progress has been made toward persuading healthcare professionals to withhold treatments that are unlikely to provide significant benefit, it is clear that a certain level of ambivalence remains with regard to withdrawing treatment. Given that the absence of clinical benefit means treating patients is not only ethically questionable but also taxing on resources that could meet the needs of others, this ambivalence is troubling. Equally, the enduring ambivalence of professionals might be taken to indicate that the issue warrants further attention. In this paper, we review the academic literature on the ethical equivalence of withdrawing and withholding medical treatment. While we are not in outright disagreement with the arguments presented, we suggest that asserting theoretical and decontextualized claims about the ethical equivalence of withdrawing and withholding life-saving treatment does not fully illuminate the moral questions associated with the relevant clinical realities. We argue that what is required is a broader perspective, one rooted in an understanding that withdrawing and withholding life-saving treatment are different practices, the meanings of which are fully comprehensible only through an appreciation of their place within the practice of healthcare more generally. Such an account suggests that if one is to engage with the inappropriate protraction of life-saving treatment resulting from healthcare professionals' disinclination to withdraw it, then the differences between these practices should be taken seriously. [ABSTRACT FROM AUTHOR]

Copyright of Annales Françaises de Médecine d'Urgence is the property of John Libbey Eurotext Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

This paper takes the philosophical notion of suberogatory acts or morally permissible moral mistakes and, via a reinterpretation of a thought experiment from the medical ethics literature, offers an initial demonstration of their relevance to the field of medical ethics. That is, at least in regards to this case, we demonstrate that the concept of morally permissible moral mistakes has a bearing on medical decision-making. We therefore suggest that these concepts may have broader importance for the discourse on medical ethics and should receive fuller consideration by those working the field. The focus of the discussion we present is on a particular thought experiment originally presented by Sulmasy and Sugarman. Their case formed the basis of an exchange about the moral equivalence of withdrawing and withholding life-saving treatment. The analysis Sulmasy and Sugarman set out is significant because, contrary to common bioethical opinion, it implies that the difference between withdrawing and withholding life-saving treatment holds, rather than lacks, moral significance. Following a brief discussion of rejoinders to Sulmasy and Sugarman’s article, we present a constructive reinterpretation of the thought experiment, one that draws on the idea of suberogatory acts or “morally permissible moral mistakes.” Our analysis, or so we suggest, accounts for the differing moral intuitions that the case prompts. However, it also calls into question the degree to which this thought experiment can be thought of as illustrating the moral (non)equivalence of withdrawing and withholding life-saving treatment. Rather, we conclude that it primarily illuminates something about the ethical parameters of healthcare when family members, particularly parents, are involved in decision-making. [ABSTRACT FROM AUTHOR]

Aims: The aims of this study were to assess the attitudes of Slovene paediatricians to aspects of end-of-life (EOL) care and compare these attitudes between paediatric intensivists, paediatric specialists and paediatric residents.Methods: We performed a cross-sectional survey, using a specifically designed 43-item anonymous questionnaire.Results: We included 323 out of 586 Slovene paediatricians and residents, while 46.7% (151 of 323) of them responded to our questionnaire. More than half of intensivists (54.2%) had sought counsel from the Committee for Medical Ethics in the past as compared with 12.0% and 12.1% of specialists and residents, respectively (P < 0.001). The decision to limit life-sustaining treatment (LST) was found to be ethically acceptable in all groups of respondents. The highest level of agreement was found in residents (90.2%), followed by 83.3% among intensivists and 73.8% among specialists (P = not statistically significant (NS)). Disagreement with termination of hydration was highest among residents (85%) and intensivists (79.2%) while it was lower among specialists (66.7%) (P = NS). Patient's best interest, good clinical practice and patient's autonomous decision were graded as the top three aspects of the EOL care, while cost effectiveness and availability of patient's bed in intensive care were the least important.Conclusions: The decision to limit LST measures was found to be ethically acceptable for Slovene paediatricians. No major differences were found among paediatric intensivists, specialist paediatricians and paediatric residents in the attitudes towards the EOL care. [ABSTRACT FROM AUTHOR]

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.

This paper is a theoretical and empirically informed examination of the naturalist distinction between withholding and withdrawing life-support. Drawing on the history of mechanical ventilation and on a recent Israeli law containing a novel approach to disconnecting life-support at the end of life, it is argued that the design of machines predicates the division line between "active" and "passive" interventions, and that the distinction itself might be morally self-defeating. Informed by insights from moral psychology, behavioral economics and philosophies of technology, the paper warns against the placement of this old distinction at the heart of the moral and legal regulation of life-support at the end of life. [ABSTRACT FROM AUTHOR]

Objective 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. Method Prospective observational study based on 1-day audit conducted from January to May 2009 in 66 southern French ICUs. Results 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 < 0.0001), advance directives ( P = 0.01), age ( P = 0.008) and the SAPS 2 score ( P = 0.009). Conclusion The major finding of the present study is the existence of a gap between the widely approved EoL recommendations made by scientific societies and the daily practice of southern French ICUs. Even if EoL decisions are mostly shared with relatives, their written documentation in medical charts remains insufficient. Concerning EoL practices, the withdrawal of treatment remains an uncommon decision. [ABSTRACT FROM AUTHOR]

Sustaining vital functions in critically ill in the ICU frequently allows prolongation of patient’s life even in circumstances where the treatment has lost its medical rationale and/or there is no hope for the patient’s condition to improve. Decision-making about termination of such treatment – usually referred to as futile, useless or inappropriate –, frequently presents a difficult ethical dilemma not only for the intensivists and other health-care workers but also for the patients and their relatives. The principles of biomedical ethics present a useful framework for decision-making in ethical dilemmas but cannot offer sufficiently explicit guidelines. Besides, the concepts of futility or futile treatment in the ICU are also not unequivocally defined. Thus, the decision regarding continuing or stopping treatment should be based on careful evaluation of the balance between its expected efficiency and benefits on the one hand and the burden imposed upon the patient on the other. If the burden clearly exceeds the expected benefits, the ethically sound decision is to terminate such treatment.

Advances in medicine can reduce active euthanasia of newborns with severe anomalies or unusual prematurity, but they cannot eliminate it. In the Netherlands, voluntary active euthanasia among adults and adolescents has been allowed since 2002, when the so-called Groningen Protocol (GP) was formulated as an extension of the law on extremely premature and severely ill newborns. It is maintained that, at bioethical level, it serves the principle of beneficence. Other European countries do not accept the GP, including Belgium. Admissibility of active euthanasia is a necessary, though inadequate, condition for acceptance of the GP. Greece generally prohibits euthanasia, although the legal doctrine considers some of the forms of euthanasia permissible, but not active or involuntary euthanasia. The wide acceptance of passive newborns euthanasia, especially when the gestational age of the newborns is 22-25 weeks ("grey zone"), admissibility of practices within the limits between active and passive euthanasia (e.g., withholding/withdrawing), of "indirect active euthanasia" and abortion of the late fetus, the tendency to accept after-birth-abortion (infanticide) in the bioethical theory, the lower threshold for application of withdrawing in neonatal intensive care units compared with pediatric intensive care units, all the above advocate wider acceptance of the GP. However, the GP paves the way for a wide application of involuntary (or pseudo-voluntary) euthanasia (slippery slope) and contains some ambiguous concepts and requirements (e.g., "unbearable suffering"). It is suggested that the approach to the sensitive and controversial ethical dilemmas concerning the severely ill newborns is done not through the GP, but rather, through a combination of virtue bioethics (especially in the countries of the so-called "Mediterranean bioethical zone") and of the principles of principlism which is enriched, however, with the "principle of mutuality" (enhancement of all values and principles, especially with the principles of "beneficence" and "justice"), in order to achieve the "maximal" bioethical approach, along with the establishment of circumstances and alternatives that minimize or eliminate the relevant bioethical dilemmas and conflicts between the fundamental principles. Thus, the most appropriate/fairest choices are made (by trained parents and physicians), considering all interests involved as much as possible. [ABSTRACT FROM AUTHOR]

Abstract: For the last 20 years or so, conflicts on life-support have become the object of widespread media coverage. By focusing public opinion on the alleged physicians’ unreasonable obstinacy, these publicized cases impact social debates on life-support. By these, they justify claims for the legalization of assisted suicide, specifically the practice of termination of life by lethal injection. Via a conducted survey of the various caretakers and families involved in this type of situation, we propose an analysis based on the different forms of unreasonable obstinacy. The reasonable or unreasonable nature of treatments can often be perceived differently by physicians, caretakers and families. At least 6 unreasonable obstinacy cases can be brought to light. Publicized cases always involve a conflict between the physicians in charge and the families who view the situation as unreasonable. Nonetheless, evidence shows that in these situations, the roles are often reversed, and the families are the ones demanding the use of unreasonable care. A typical example of this is a recent case that became the object of legal proceedings in France. As it turns out, the publicized filter does not reflect the true reality of cases involving unreasonable care. Specific procedures could aid in notifying the existence of such situations. The role of health care professionals (excluding physicians) appears to play an essential part in preventing these situations from happening. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

Purpose: This study was designed to assess the ethical attitudes and practices of intensive care physicians regarding life-sustaining treatment in intensive care units (ICUs) in Poland. Methods: A questionnaire was distributed to intensive care physicians taking part in a national medical congress. Participation in the study was voluntary and anonymous. Results: A total of 400 questionnaires were distributed, of which 217 (54%) were returned completed. Almost all respondents (93%) reported having withheld therapy, and 75% of respondents reported withdrawing therapy. Physicians aged 40 years and over who had no religious affiliation more frequently reported withholding treatment. Only 5% of physicians reported deliberately administering drugs until death ensued. Respondents from large hospitals (more than 400 beds) more easily accepted foregoing life-sustaining therapy in ICU patients. In clinical scenario in which the family demanded the maximum available treatment, physicians reported that they were considerably influenced to modify decisions concerning life-sustaining therapy. Conclusions: The ethical attitudes of intensive care physicians regarding end-of-life decisions are similar to the opinion presented in other European survey studies. The practice of withholding and withdrawing therapy in ICU patients is common in Poland. Actively shortening life is considered unacceptable. The request of the family even without legal consultation can influence physicians' decisions. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Frequently, ethical dilemmas for clinicians in ICU focus on the conflict between the sanctity of life principle and other important ethical principles, such as patient autonomy or quality of life. Therefore, this chapter seeks to reveal the ethical tension between the sanctity of life and other competing ethical obligations, clearly outlining how the law in reality is making decisions and what a clinician''s duties are in end of life issues. [Copyright &y& Elsevier]

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Introduction: Over the last several years, there have been legal decisions and changes in medical directives concerning end-of-life decisions in Israel. Methods: The data were compared to evaluate the changes in the frequency and types of forgoing of life-sustaining treatment (FLST) in patients who were admitted to the ICU during period I (November 1994 to July 1995) and period II (January 1998 to January 1999). Results: During period I, there were 385 ICU admissions, and during period II there were 627 ICU admissions. In period I, FLST or death occurred in 13.5% of patients, and in 12% in period II. There was no significant difference in cardiopulmonary resuscitation (9% vs 13%, respectively), withholding therapy (90% vs 91%, respectively), or withdrawing therapy (0% vs 0%, respectively) between the two study periods. Conclusions: There was no significant change in the frequency or types of FLST in an Israeli ICU between 1994 and 1998, despite passage of a new Patients' Rights Law and the issuing of a Ministry of Health directive on the treatment of the terminally ill, both of which occurred in 1996, and recent district court decisions favoring the termination of life-sustaining therapies. [ABSTRACT FROM AUTHOR]

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Objective: To describe a four-step protocol for withholding and withdrawal of life support (WH/WDLS) in intensive care unit (ICU) terminal patients.Design: Observational study.Setting: A 10-bed ICU of a general hospital.Patients: Eighty-three patients out of 475 consecutive patients admitted over a 1 year period had WH/WDLS.Interventions: The healthcare team chose a pattern of treatment limitation on a four-step protocol for every patient every day. There were four alternatives: group 1: no limitation of care; group 2: patient designated do not resuscitate (DNR) and pressors limited to dopamine at a maximum dose of 20 microg/kg per min; others therapies were continued; group 3: active withdrawal of all therapy except comfort care, i.e., the patient continued to receive nursing, sedation/analgesia, hydration and mechanical ventilation with FIO2=0.21 and no positive end-expiratory pressure (PEEP). Sedation was adjusted to Ramsay 3-4. The group 4 was treated the same as group 3 except that minute ventilation was 5 l/min and sedation/analgesia adjusted to Ramsay 6. WH/WDLS was performed only if the full ICU staff and all family members agreed with the procedure. WH/WDLS was documented in the patient's chart.Results: Withholding and withdrawal of life support was performed in 83 patients (17%): 25 patients in group 2 (15 deaths), 36 patients in group 3 (36 deaths) and 22 patients in group 4 (22 deaths). Finally, 73 patients died after WH/WDLS. ICU stay was 10+/-17 days, time from admission to WH/WDLS was 184+407 h and time from WH/WDLS to death was 64+/-84 h.Conclusion: This four-step protocol may promote medical decision making on end-of-life care. [ABSTRACT FROM AUTHOR]

In this article we describe one way to use value premises, i.e. conceptions of what is right or wrong, good or bad, just or unjust. They may, in combination with the results from surveys on attitudes, be used to defend normative conclusions, for example changes in professional guidelines. Several ethical principles may be relevant when discussing an end-of-life decision. We use the preferences of those involved in or affected by that decision (the principle of autonomy) and the obligation to maximize benefits and minimize harm (the principle of beneficence) as value premises. To illustrate the ethical, empirical and logical issues relevant to assess normative conclusions, we present a Swedish survey of the attitudes of health care workers and the general public. In this survey, the physicians stated that they do not want the family to be the sole decision-maker, whilst the public did not want the physician to be the sole decision-maker. As a third option we propose joint decision-making regarding end-of-life decisions. This normative conclusion may be rationally discussed, not only by questioning scientific aspects of the survey, but also by critically assessing value premises (autonomy and beneficence) and the logic of the argument. [ABSTRACT FROM AUTHOR]

Objective: To determine whether physicians in Israel withhold and/or withdraw life-sustaining treatments.Design: A prospective, descriptive study of consecutively admitted patients. Patients were prospectively evaluated for diagnoses, types and reasons for foregoing life-sustaining treatment, mortality and times from foregoing therapy until mortality.Setting: A general intensive care unit of a university hospital in Israel.Results: Foregoing life-sustaining treatment occurred in 52 (13.5%) of 385 patients admitted and 5 (1%) had cardiopulmonary resuscitation. Withholding therapy occurred in 48 patients. Four patients with brain death had all treatments withdrawn. No patient had antibiotics, nutrition or fluids withheld or withdrawn. Time from foregoing therapy until death was 2.9 +/- 0.6 days. Thirty-one of 48 (65%) patients who had therapy withheld died within 48 h.Conclusions: Withholding life-prolonging treatments is common in an Israeli intensive care unit whereas withdrawing therapy is limited to brain dead patients. Terminal patients die soon after withholding, even if the therapy is not withdrawn. Withholding treatments should be an option for patients and professionals who object to withdrawing therapies. [ABSTRACT FROM AUTHOR]

Objectives: First, to present the position on the distinction between withholding and withdrawing life-sustaining treatment as expressed in guidelines and examine its relation to the attitudes of health care professionals. Second, to examine the possible ethical justification of this distinction.Design, Setting, and Participants: Critical analysis of guidelines on life-sustaining treatment and questionnaire administered to 148 health care professionals--physicians and nurses at the intensive care unit (ICU), University Hospital MAS, Malmö, Sweden.Results: In contrast to the guidelines, which emphasize that there is no ethical difference between withholding and withdrawing life-sustaining treatment, not less than 50 per cent of the professionals in the ICU were of the opinion that there is an ethical difference. All attempts to justify this difference with reference to an inherent distinction between withholding and withdrawing seem to be controversial.Conclusions: We recommend a change in emphasis in professional guidelines. Such guidelines should avoid the controversial issue about the possible inherent ethical difference between withholding and withdrawing life-sustaining treatment. What should be underlined is that the particular situation and the consequences of withholding as well as withdrawing life-sustaining treatment should always be taken into account. [ABSTRACT FROM AUTHOR]

The authors suggested that this is the responsibility of physicians who are following patients with chronic and/or terminal diseases to obtain advance directives from patients in case they would not be able to communicate. It has been established that there is a lack of advance directives among patients admitted in emergency departments, especially for those coming from nursing homes despite the fact that advance directives could be useful to guide emergency care [2]. [Extracted from the article]

During the last two decades there has been an enormous development in treatment possibilities for the extremely premature infants and the Neonatologists have to face in their daily practice many decisional problems and ethical, moral and legal dilemmas. These concern decisions to initiate or withhold treatment directly at birth, decision to withdrawn treatment with the possible consequence that the child will die. The debate between 'sanctity' and 'quality' of life, aggressive treatment in relation to discrimination toward the disabled, the principle of 'beneficence' and the question of 'proportionality' of treatment, the concept of the newborn's 'best interest' are the ethical issues discussed. According to our opinion, ethical questions should not be regulated by law and the legal system should not interfere in the relationship patient - physician. Today more than ever, every neonatologist needs to become familiar with basic ethical concepts and the legal aspects in neonatal intensive care. [ABSTRACT FROM AUTHOR]