The impact of country and culture on end-of-life care for injured patients: results from an international survey.
BACKGROUND
Up to 20% of all trauma patients admitted to an intensive care unit die from their injuries. End-of-life decision making is a variable process that involves prognosis, predicted functional outcomes, personal beliefs, institutional resources, societal norms, and clinician experience. The goal of this study was to better understand end-of-life processes after major injury by comparing clinician viewpoints from various countries and cultures.


METHODS
A clinician-based, 38-question international survey was used to characterize the impacts of medical, religious, social, and system factors on end-of-life care after trauma.


RESULTS
A total of 419 clinicians from the United States (49%), Canada (19%), South Africa (11%), Europe (9%), Asia (8%), and Australasia (4%) completed the survey. In America, the admitting surgeon guided most end-of-life decisions (51%), when compared with all other countries (0-27%). The practice structure of American respondents also varied from other regions. Formal medical futility laws are rarely available (14-38%). Ethical consultation services are often accessible (29-98%), but rarely used (0-29%), and typically unhelpful (<30%). End-of-life decision making for patients with traumatic brain injuries varied extensively across regions with regard to the impact of patient age, Glasgow Coma Scale score, and clinician philosophy. Similar differences were observed for spinal cord injuries (age and functional level). The availability and use of "donation after cardiac death" also varied substantially between countries.


CONCLUSIONS
In this unique study, geographic differences in religion, practice composition, decision-maker viewpoint, and institutional resources resulted in significant variation in end-of-life care after injury. These disparities reflect competing concepts (patient autonomy, distributive justice, and religion).
Department of Surgery, Emory University, Grady Memorial Hospital, Atlanta, Georgia, USA.
Chad G
CG
Ball
Pradeep
P
Navsaria
Andrew W
AW
Kirkpatrick
Christian
C
Vercler
Elijah
E
Dixon
John
J
Zink
Kevin B
KB
Laupland
Michael
M
Lowe
Jeffrey P
JP
Salomone
Christopher J
CJ
Dente
Amy D
AD
Wyrzykowski
S Morad
SM
Hameed
Sandy
S
Widder
Kenji
K
Inaba
Jill E
JE
Ball
Grace S
GS
Rozycki
Sean P
SP
Montgomery
Thomas
T
Hayward
David V
DV
Feliciano
D001208:Asia; D001291:Attitude of Health Personnel; D044362:Australasia; D002170:Canada; D003469:Culture; D003657:Decision Making; D005060:Europe; D006295:Health Resources; D006801:Humans; D007362:Intensive Care Units; D018447:Medical Futility / Q000331:legislation & jurisprudence; D010817:Physician-Patient Relations; D012067:Religion; D013019:South Africa; D011795:Surveys and Questionnaires; D013727:Terminal Care; D009927:Tissue and Organ Procurement; D014481:United States