International Differences in End-of-Life Attitudes in the Intensive Care Unit

Abstract

Discussions about end-of-life issues have become common, especially in the Western medical literature. Advances in medical technology and therapies enable more lives to be saved but sometimes may merely prolong the dying process. Recent studies^1,2 have shown that the exact timing of death is often under the control of the physicians who care for the patient. This is particularly true in the intensive care unit (ICU),³ where death is commonly preceded by decisions not to start aggressive therapy (withholding) or to discontinue life-sustaining therapy (withdrawing). The question of who should be responsible for decision making is a difficult issue; the patient is often unable to participate in this decision, and the roles of the medical team, the relatives, and the legal system are highly variable in different parts of the world, adding to the variability of these end-of-life decisions and the difficulty in achieving an international consensus on these issues. Numerous reports exist on this topic,^4-13 and several surveys have been conducted^2,14-25; however, these surveys were limited to national or geographic regions, and no large international survey has been performed. As previous studies have shown,^14,17,18,20 substantial differences exist among European countries. Furthermore, the guidelines in the United States²⁶ are also different from those within Europe.^27,28 Although some would defend the need for the development of an international consensus or a global system of ethics,³ this may not be achievable or even desirable. In a recent survey of physicians involved in end-of-life care in 6 European countries and Australia, Miccinesi et al²⁹ reported that country was the strongest determinant of physician attitude toward end-of-life decisions, although the individual physician characteristics of age, religious beliefs, sex, and previous experience with dying patients were also strong determinants. Other studies^{11,14,17,18,29,30} have shown the strong influence of religion, culture, race, legal background, social factors, and tradition on attitudes toward end-of-life issues. In addition, these issues are influenced by and change with temporal trends,^11,14,17 as illustrated by the Hippocratic Oath, which recognized the importance of the principles of beneficence, nonmaleficience, and medical futility but did not discuss autonomy or distributive justice. During the last 4 decades, autonomy and distributive justice have become increasingly predominant.