title: Policies of withholding and withdrawal of life-sustaining treatment in critically ill patients on cardiac intensive care units in Germany: a national survey.
abstract: OBJECTIVE
  To determine the decision-making process of withholding and/or withdrawal (WH/WD) of life-sustaining treatment in cardiac intensive care units (ICUs) in Germany.
  
  
  METHODS
  A questionnaire regarding 16 medical and 6 ethical questions of WH/WD of life-sustaining treatment was distributed to the clinical director, senior ICU physician and head nurses of all German heart surgery centres (n = 237 questionnaires). Furthermore, we present a literature survey using the key words 'End-of-life care AND withholding/withdrawal of life support therapy AND intensive care unit'.
  
  
  RESULTS
  We received replies from 86 of 237 (36.3%) contacted persons. Concerning medical reasons, cranial computed tomography (CCT) with poor prognosis (91.9%), multi-organ failure (70.9%) and failure of assist device therapy (69.8%) were the three most frequently cited medical reasons for WH/WD life-sustaining treatment. Overall, 32.6% of persons answered that ethical aspects influence their decision-making processes. Poor expected quality of life (48.8%), the patient's willingness to limit medical care (40.7%) and the families' choice (27.9%) were the top three reported ethical reasons. There was a significant difference regarding the perception of the three involved professional groups concerning the decision-making parameters: multi-organ failure (P = 0.018), failure of assist device therapy (P = 0.001), cardiac index (P = 0.009), poor expected quality of life (P = 0.009), the patient's willingness to limit medical care (P = 0.002), intraoperative course (P = 0.054), opinion of family members (P = 0.032) and whether decision-making process are done collaboratively (clinical director, 45.7%; ICU physician, 52%; and head of nursing staff, 26.9%). Palliation medication in patients after WH/WD of life-support consisted of morphine (92%) and benzodiazepines (88%).
  
  
  CONCLUSIONS
  This survey is a step towards creating standards of end-of-life care in cardiac ICUs, which may contribute to build consensus and avoid conflicts among caregivers, patients and families at each step of the decision-making process.
authors.affiliation: Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany. schimmer_c@klinik.uni-wuerzburg.de
authors.forename: Christoph
authors.initials: C
authors.lastname: Schimmer
authors.forename: Armin
authors.initials: A
authors.lastname: Gorski
authors.forename: Mehmet
authors.initials: M
authors.lastname: Özkur
authors.forename: Sebastian-Patrick
authors.initials: SP
authors.lastname: Sommer
authors.forename: Khaled
authors.initials: K
authors.lastname: Hamouda
authors.forename: Johannes
authors.initials: J
authors.lastname: Hain
authors.forename: Ivan
authors.initials: I
authors.lastname: Aleksic
authors.forename: Rainer
authors.initials: R
authors.lastname: Leyh
mesh_terms: D006348:Cardiac Surgical Procedures; D003325:Coronary Care Units; D016638:Critical Illness / Q000523:psychology / Q000628:therapy*; D003657:Decision Making / Q000941:ethics*; D005066:Euthanasia, Passive / Q000941:ethics*; D005858:Germany; D006801:Humans; D008020:Life Support Care / Q000941:ethics / Q000592:standards*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D028761:Withholding Treatment / Q000941:ethics / Q000592:standards* / Q000706:statistics & numerical data