Managing end-of-life decision making in intensive care medicine--a perspective from Charité Hospital, Germany.
BACKGROUND
End-of-life-decisions (EOLD) have become an important part of modern intensive care medicine. With increasing therapeutic possibilities on the one hand and many ICU-patients lacking decision making capacity or an advance directive on the other the decision making process is a major challenge on the intensive care unit (ICU). Currently, data are poor on factors associated with EOLD in Germany. In 2009, a new law on advance directives binding physicians and the patient's surrogate decision makers was enacted in Germany. So far it is unknown if this law influenced proceedings of EOLD making on the ICU.


METHODS
A retrospective analysis was conducted on all deceased patients (n = 224) in a 22-bed surgical ICU of a German university medical center from 08/2008 to 09/2010. Patient characteristics were compared between patients with an EOLD and those without an EOLD. Patients with an EOLD admitted before and after change of legislation were compared with respect to frequencies of EOLD performance as well as advance directive rates.


RESULTS
In total, 166 (74.1%) of deaths occurred after an EOLD. Compared to patients without an EOLD, comorbidities, ICU severity scores, and organ replacement technology did not differ significantly. EOLDs were shared within the caregiverteam and with the patient's surrogate decision makers. After law enacting, no differences in EOLD performance or frequency of advance directives (8.9% vs. 9.9%; p = 0.807) were observed except an increase of documentation efforts associated with EOLDs (18.7% vs. 43.6%; p<0.001).


CONCLUSIONS
In our ICU EOLD proceedings were performed patient-individually. But EOLDs follow a standard of shared decision making within the caregiverteam and the patient's surrogate decision makers. Enacting a law on advance directives has not affected the decision making-process in EOLDs nor has it affected population's advance care planning habits. However, it has led to increased EOLD-associated documentation on the ICU.


BACKGROUND
[corrected] ClinicalTrials.gov NCT01294189.
Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany. jan.graw@charite.de
Jan A
JA
Graw
Claudia D
CD
Spies
Klaus-D
KD
Wernecke
Jan-Peter
JP
Braun
D016223:Advance Directives / Q000266:history / Q000331:legislation & jurisprudence*; D003422:Critical Care; D003657:Decision Making; D005858:Germany; D049674:History, 21st Century; D006801:Humans; D008020:Life Support Care / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data; D010819:Physician's Role; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D013727:Terminal Care / Q000331:legislation & jurisprudence* / Q000379:methods