title: Withholding and withdrawal of life-sustaining treatments in intensive care units in Asia.
abstract: OBJECTIVE
  Little data exist on end-of-life care practices in intensive care units (ICUs) in Asia.
  
  
  OBJECTIVE
  To describe physicians' attitudes toward withholding and withdrawal of life-sustaining treatments in end-of-life care and to evaluate factors associated with observed attitudes.
  
  
  METHODS
  Self-administered structured and scenario-based survey conducted among 1465 physicians (response rate, 59.6%) who manage patients in ICUs (May-December 2012) at 466 ICUs (response rate, 59.4%) in 16 Asian countries and regions.
  
  
  RESULTS
  For patients with no real chance of recovering a meaningful life, 1029 respondents (70.2%) reported almost always or often withholding whereas 303 (20.7%) reported almost always or often withdrawing life-sustaining treatments; 1092 respondents (74.5%) deemed withholding and withdrawal ethically different. The majority of respondents reported that vasopressors, hemodialysis, and antibiotics could usually be withheld or withdrawn in end-of-life care, but not enteral feeding, intravenous fluids, and oral suctioning. For severe hypoxic-ischemic encephalopathy after cardiac arrest, 1201 respondents (82.0% [range between countries, 48.4%-100%]) would implement do-not-resuscitate orders, but 788 (53.8% [range, 6.1%-87.2%]) would maintain mechanical ventilation and start antibiotics and vasopressors if indicated. On multivariable analysis, refusal to implement do-not-resuscitate orders was more likely with physicians who did not value families' or surrogates' requests (adjusted odds ratio [AOR], 1.67 [95% CI, 1.16-2.40]; P = .006), who were uncomfortable discussing end-of-life care (AOR, 2.38 [95% CI, 1.62-3.51]; P < .001), who perceived greater legal risk (AOR, 1.92 [95% CI, 1.26-2.94]; P = .002), and in low- to middle-income economies (AOR, 2.73 [95% CI, 1.56-4.76]; P < .001). Nonimplementation was less likely with physicians of Protestant (AOR, 0.36 [95% CI, 0.16-0.80]; P = .01) and Catholic (AOR, 0.22 [95% CI, 0.09-0.58]; P = .002) faiths, and when out-of-pocket health care expenditure increased (AOR, 0.98 per percentage of total health care expenditure [95% CI, 0.97-0.99]; P = .02).
  
  
  CONCLUSIONS
  Whereas physicians in ICUs in Asia reported that they often withheld but seldom withdrew life-sustaining treatments at the end of life, attitudes and practice varied widely across countries and regions. Multiple factors related to country or region, including economic, cultural, religious, and legal differences, as well as personal attitudes, were associated with these variations. Initiatives to improve end-of-life care in Asia must begin with a thorough understanding of these factors.
authors.affiliation: Division of Respiratory and Critical Care Medicine, National University Hospital, National University Health System, Singapore.
authors.forename: Jason
authors.initials: J
authors.lastname: Phua
authors.affiliation: Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
authors.forename: Gavin M
authors.initials: GM
authors.lastname: Joynt
authors.affiliation: Emergency and Critical Care Medicine, University of Tokushima Graduate School, Tokushima, Japan.
authors.forename: Masaji
authors.initials: M
authors.lastname: Nishimura
authors.affiliation: Intensive Care Unit, West China Hospital of Sichuan University, Sichuan, China.
authors.forename: Yiyun
authors.initials: Y
authors.lastname: Deng
authors.affiliation: Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India.
authors.forename: Sheila Nainan
authors.initials: SN
authors.lastname: Myatra
authors.affiliation: Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Yiong Huak
authors.initials: YH
authors.lastname: Chan
authors.affiliation: Intensive Care Department, Bach Mai Hospital, Hanoi, Vietnam.
authors.forename: Nguyen Gia
authors.initials: NG
authors.lastname: Binh
authors.affiliation: Department of Anaesthesia and Intensive Care, Sultanah Aminah Hospital, Johor Bahru, Malaysia.
authors.forename: Cheng Cheng
authors.initials: CC
authors.lastname: Tan
authors.affiliation: Department of Critical Care Medicine, BIRDEM General Hospital, Ibrahim Medical College, Dhaka, Bangladesh.
authors.forename: Mohammad Omar
authors.initials: MO
authors.lastname: Faruq
authors.affiliation: Intensive Care Department, Kian Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: Yaseen M
authors.initials: YM
authors.lastname: Arabi
authors.affiliation: Department of Anesthesiology and Reanimation, University of Airlangga, Dr Soetomo General Hospital, Surabaya, Indonesia.
authors.forename: Bambang
authors.initials: B
authors.lastname: Wahjuprajitno
authors.affiliation: Department of Respiratory Therapy, Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
authors.forename: Shih-Feng
authors.initials: SF
authors.lastname: Liu
authors.affiliation: Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Seyed Mohammad Reza
authors.initials: SM
authors.lastname: Hashemian
authors.affiliation: Section of Nephrology, Pulmonary and Critical Care, Department of Medicine, Aga Khan University and Hospital, Karachi, Pakistan.
authors.forename: Waqar
authors.initials: W
authors.lastname: Kashif
authors.affiliation: Phramongkutklao Hospital, Bangkok, Thailand.
authors.forename: Dusit
authors.initials: D
authors.lastname: Staworn
authors.affiliation: Section of Adult Critical Care Medicine, Department of Medicine, The Medical City, Pasig City, Philippines.
authors.forename: Jose Emmanuel
authors.initials: JE
authors.lastname: Palo
authors.affiliation: Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
authors.forename: Younsuck
authors.initials: Y
authors.lastname: Koh
mesh_terms: D000328:Adult; D001208:Asia; D001291:Attitude of Health Personnel; D003657:Decision Making; D004992:Ethics, Medical; D005190:Family / Q000523:psychology; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008020:Life Support Care; D008297:Male; D008875:Middle Aged; D010820:Physicians; D016414:Resuscitation Orders; D013727:Terminal Care; D028761:Withholding Treatment