Pattern of end-of-life decisions in two Tunisian intensive care units: the role of culture and intensivists' training.
OBJECTIVE
End-of-life (EOL) decisions are not well studied in developing countries. We report EOL decision patterns in two Tunisian intensive care units [ICUs, medical (MICU) and surgical (SICU)] belonging to the same teaching hospital.


METHODS
Consecutive deaths that occurred in participating ICUs over 2 years were analysed. End-of-life decisions were prospectively recorded by the senior attending physicians, while subject's characteristics were retrospectively collected.


RESULTS
Deaths occurred in 326 of 1,733 ICU-admitted patients (median age: 64 years; median SAPS II at admission = 36). Overall, a decision for full support was taken in 69%, while decisions to withhold or withdraw life support were held in 22.1 and 8.9% of deaths, respectively. The rate of end-of-life decisions was similar in the MICU and the SICU. In no instance was there MV withdrawal during ICU stay. Discharging patients to die at home was observed only in the MICU (10 out of the 20 patients with a withdrawal decision). Two factors were independently associated with WH or WD decisions: a severe and ultimately fatal underlying disease was positively associated with such decisions (OR = 2.4, 95% CI: 1.3-4.36; p = 0.003), while having an independent functional status before the ICU was associated with a decreased rate of physician decisions of WH or WD (OR = 0.32, 95% CI: 0.15-0.67; p = 0.002).


CONCLUSIONS
Withholding and withdrawing life support are common in medical and surgical ICUs of a Tunisian hospital. Withholding is more frequent than withdrawing life support. These decisions appear to be effected by functional status and underlying conditions.
Medical Intensive Care Unit, Fattouma Bourguiba University Hospital, University of Monastir, 5000 Monastir, Tunisia.
Islem
I
Ouanes
Néji
N
Stambouli
Fahmi
F
Dachraoui
Lamia
L
Ouanes-Besbes
Samir
S
Toumi
Faouzi
F
Ben Salem
Mourad
M
Gahbiche
Fekri
F
Abroug
D000368:Aged; D016009:Chi-Square Distribution; D003466:Cultural Characteristics; D003657:Decision Making; D003906:Developing Countries; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006784:Hospitals, Teaching; D006801:Humans; D007362:Intensive Care Units; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D012307:Risk Factors; D018709:Statistics, Nonparametric; D013727:Terminal Care; D014416:Tunisia