title: Withholding and withdrawing life-sustaining therapy in a Moroccan Emergency Department: an observational study.
abstract: BACKGROUND
  Withdrawing and withholding life-support therapy (WH/WD) are undeniably integrated parts of medical activity. However, Emergency Department (ED) might not be the most appropriate place to give end-of life (EOL) care; the legal aspects and practices of the EOL care in emergency rooms are rarely mentioned in the medical literature and should be studied. The aims of this study were to assess frequency of situations where life-support therapies were withheld or withdrawn and modalities for implement of these decisions.
  
  
  METHODS
  A survey of patients who died in a Moroccan ED was performed. Confounding variables examined were: Age, gender, chronic underlying diseases, acute medical disorders, APACHE II score, Charlson Comorbidities Index, and Length of stay. If a decision of WH/WD was taken, additional data were collected: Type of decision; reasons supporting the decision, modalities of WH/WD, moment, time from ED admission to decision, and time from processing to withhold or withdrawal life-sustaining treatment to death. Individuals who initiated (single emergency physician, medical staff), and were involved in the decision (nursing staff, patients, and families), and documentation of the decision in the medical record.
  
  
  RESULTS
  177 patients who died in ED between November 2009 and March 2010 were included. Withholding and withdrawing life-sustaining treatment was applied to 30.5% of all patients who died. Therapies were withheld in 24.2% and were withdrawn in 6.2%. The most reasons for making these decisions were; absence of improvement following a period of active treatment (61.1%), and expected irreversibility of acute disorder in the first 24 h (42.6%). The most common modalities withheld or withdrawn life-support therapy were mechanical ventilation (17%), vasopressor and inotrops infusion (15.8%). Factors associated with WH/WD decisions were older age (OR = 1.1; 95%IC = 1.01-1.07; P = 0.001), neurological acute medical disorders (OR = 4.1; 95%IC = 1.48-11.68; P = 0.007), malignancy (OR = 7.7; 95%IC = 1.38-8.54; P = 0.002) and cardiovascular (OR = 3.4;95%IC = 2.06-28.5;P = 0.008) chronic underlying diseases.
  
  
  CONCLUSIONS
  Life-sustaining treatment were frequently withheld or withdrawn from elderly patients with underlying chronic cardiovascular disease or metastatic cancer or patients with acute neurological medical disorders in a Moroccan ED. Religious beliefs and the lack of guidelines and official Moroccan laws could explain the ethical limitations of the decision-making process recorded in this study.
authors.affiliation: Medical Emergency Department, Ibn Sina University Hospital, 10000, Rabat, Morocco.
authors.forename: Nada
authors.initials: N
authors.lastname: Damghi
authors.forename: Jihane
authors.initials: J
authors.lastname: Belayachi
authors.forename: Badria
authors.initials: B
authors.lastname: Aggoug
authors.forename: Tarek
authors.initials: T
authors.lastname: Dendane
authors.forename: Khalid
authors.initials: K
authors.lastname: Abidi
authors.forename: Naoufel
authors.initials: N
authors.lastname: Madani
authors.forename: Aicha
authors.initials: A
authors.lastname: Zekraoui
authors.forename: Abdellatif Benchekroun
authors.initials: AB
authors.lastname: Belabes
authors.forename: Amine Ali
authors.initials: AA
authors.lastname: Zeggwagh
authors.forename: Redouane
authors.initials: R
authors.lastname: Abouqal
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D004630:Emergencies / Q000453:epidemiology*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008020:Life Support Care / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009018:Morocco / Q000453:epidemiology; D012189:Retrospective Studies; D055815:Young Adult