title: End-of-life decisions in Greek intensive care units: a multicenter cohort study.
abstract: BACKGROUND
  Intensive care may prolong the dying process in patients who have been unresponsive to the treatment already provided. Limitation of life-sustaining therapy, by either withholding or withdrawing support, is an ethically acceptable and common worldwide practice. The purpose of the present study was to examine the frequency, types, and rationale of limiting life support in Greek intensive care units (ICUs), the clinical and demographic parameters associated with it, and the participation of relatives in decision making.
  
  
  METHODS
  This was a prospective observational study conducted in eight Greek multidisciplinary ICUs. We studied all consecutive ICU patients who died, excluding those who stayed in the ICU less than 48 hours or were brain dead.
  
  
  RESULTS
  Three hundred six patients composed the study population, with a mean age of 64 years and a mean APACHE II score on admission of 21. Of study patients, 41% received full support, including unsuccessful cardiopulmonary resuscitation (CPR); 48% died after withholding of CPR; 8%, after withholding of other treatment modalities besides CPR; and 3%, after withdrawal of treatment. Patients in whom therapy was limited had a longer ICU (P < 0.01) and hospital (P = 0.01) length of stay, a lower Glasgow Coma Scale score (GCS) on admission (P < 0.01), a higher APACHE II score 24 hours before death (P < 0.01), and were more likely to be admitted with a neurologic diagnosis (P < 0.01). Patients who received full support were more likely to be admitted with either a cardiovascular (P = 0.02) or trauma diagnosis (P = 0.05) and to be surgical rather than medical (P = 0.05). The main factors that influenced the physician's decision were, when providing full support, reversibility of illness and prognostic uncertainty, whereas, when limiting therapy, unresponsiveness to treatment already offered, prognosis of underlying chronic disease, and prognosis of acute disorder. Relatives' participation in decision making occurred in 20% of cases and was more frequent when a decision to provide full support was made (P < 0.01). Advance directives were rare (1%).
  
  
  CONCLUSIONS
  Limitation of life-sustaining treatment is a common phenomenon in the Greek ICUs studied. However, in a large majority of cases, it is equivalent to the withholding of CPR alone. Withholding of other therapies besides CPR and withdrawal of support are infrequent. Medical paternalism predominates in decision making.
authors.affiliation: First Critical Care Department, Evangelismos Hospital, National and Kapodistrian University of Athens, 45-47 Ypsilantou Str, Athens, 10675, Greece.
authors.forename: Georgios
authors.initials: G
authors.lastname: Kranidiotis
authors.forename: Vasiliki
authors.initials: V
authors.lastname: Gerovasili
authors.forename: Athanasios
authors.initials: A
authors.lastname: Tasoulis
authors.forename: Elli
authors.initials: E
authors.lastname: Tripodaki
authors.forename: Ioannis
authors.initials: I
authors.lastname: Vasileiadis
authors.forename: Eleni
authors.initials: E
authors.lastname: Magira
authors.forename: Vasiliki
authors.initials: V
authors.lastname: Markaki
authors.forename: Christina
authors.initials: C
authors.lastname: Routsi
authors.forename: Athanasios
authors.initials: A
authors.lastname: Prekates
authors.forename: Theodoros
authors.initials: T
authors.lastname: Kyprianou
authors.forename: Phyllis-Maria
authors.initials: PM
authors.lastname: Clouva-Molyvdas
authors.forename: Georgios
authors.initials: G
authors.lastname: Georgiadis
authors.forename: Ioannis
authors.initials: I
authors.lastname: Floros
authors.forename: Andreas
authors.initials: A
authors.lastname: Karabinis
authors.forename: Serafim
authors.initials: S
authors.lastname: Nanas
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003657:Decision Making; D005260:Female; D006115:Greece / Q000453:epidemiology; D006801:Humans; D007362:Intensive Care Units; D008020:Life Support Care / Q000379:methods* / Q000523:psychology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000379:methods* / Q000523:psychology; D028761:Withholding Treatment