title: Practices of end-of-life decisions in 66 southern French ICUs 4 years after an official legal framework: A 1-day audit.
abstract: OBJECTIVE
  Since the implementation of two French laws in 2002 and 2005 and the implementation of guidelines about End-of-Life (EoL) decisions, few studies concerning EoL practices in French intensive care units (ICUs) have been reported. This study was aimed at assessing compliance with recommendations and current legislation concerning EoL decisions.
  
  
  METHODS
  Prospective observational study based on 1-day audit conducted from January to May 2009 in 66 southern French ICUs.
  
  
  RESULTS
  Six hundred and twenty-five patients were included (median age: 63 [52-76] years, median SAPS II: 46 [34-58]). The written designation of a surrogate decision-maker was reported for 87 (15%) patients. Advance directives were completed for only 4% of patients. The EoL decision-making process consisted in a multidisciplinary approach for 99 (47%) patients and was recorded in the medical chart for 63 (64%) cases. Families were informed about medical decisions in 58% of cases. This proportion was higher (87%) if a decision to forego life-sustaining therapy was made. EoL decisions consisted of withholding treatments for 72 (94%) patients and withdrawal of treatments for 5 (6%) patients. In the multivariate stepwise logistic regression, four variables were independently associated with a decision to forego life support: preexisting dependence on others (P<0.0001), advance directives (P=0.01), age (P=0.008) and the SAPS 2 score (P=0.009).
  
  
  CONCLUSIONS
  The major finding of the present study is the existence of a gap between the widely approved EoL recommendations made by scientific societies and the daily practice of southern French ICUs. Even if EoL decisions are mostly shared with relatives, their written documentation in medical charts remains insufficient. Concerning EoL practices, the withdrawal of treatment remains an uncommon decision.
authors: Pôle Anesthésie Réanimation Douleur Urgences, CHU de Nîmes, place du Pr-Debré, 30029 Nîmes, France. Electronic address: claire.roger@chu-nimes.fr.
authors: Claire
authors: C
authors: Roger
authors: Service d'Anesthésie Réanimation, Hôpital Nord, 42055 Saint-Étienne Cedex 2, France.
authors: Jérome
authors: J
authors: Morel
authors: UMR 729, Service DIM, CHRU de Montpellier, Hôpital la Colombière, 39, avenue Charles-Flahaut, 34091 Montpellier Cedex 5, France.
authors: Nicolas
authors: N
authors: Molinari
authors: Réanimation Médico-Chirurgicale, Hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06001 Nice cedex 1, France.
authors: Jean Christophe
authors: JC
authors: Orban
authors: Département d'Anesthésie Réanimation, Hôpital Saint-Eloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier Cedex 5, France; InsermU-1046, Université Montpellier I, Université Montpellier II, 34295 Montpellier cedex 5, France.
authors: Boris
authors: B
authors: Jung
authors: Département d'Anesthésie Réanimation, Hôpital Estaing, CHU de Clermont-Ferrand, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand Cedex 1, France.
authors: Emmanuel
authors: E
authors: Futier
authors: Hospices Civils de Lyon, Groupement Hospitalier est, Département d'Anesthésie Réanimation, Hôpital Louis-Pradel, Université Claude-Bernard Lyon 1, 59, boulevard Pinel, 69677 Bron, France.
authors: Olivier
authors: O
authors: Desebbe
authors: Hospices Civils de Lyon, Hôpital Lyon Sud, Département d'Anesthésie Réanimation, 165, chemin du Grand-Revoyet, 69495 Pierre Bénite, France.
authors: Arnaud
authors: A
authors: Friggeri
authors: Service d'Anesthésie Réanimation, Hôpital Purpan, place du Docteur-Baylac, 31059 Toulouse, France.
authors: Stein
authors: S
authors: Silva
authors: Pôle Anesthésie Réanimation, CHU de Grenoble, 38700 La Tronche, Grenoble, France.
authors: Pierre
authors: P
authors: Bouzat
authors: Service d'Anesthésie et de Réanimation, AP-HM, Hôpital Nord, Aix Marseille Université, 13915 Marseille cedex 20, France.
authors: Benoit
authors: B
authors: Ragonnet
authors: Service d'Anesthésie Réanimation, Groupement Hospitalier Édouard-Herriot, 69003 Lyon, France.
authors: Bernard
authors: B
authors: Allaouchiche
authors: Département d'Anesthésie Réanimation, Hôpital Estaing, CHU de Clermont-Ferrand, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand Cedex 1, France.
authors: Jean-Michel
authors: JM
authors: Constantin
authors: Réanimation Médico-Chirurgicale, Hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06001 Nice cedex 1, France.
authors: Carole
authors: C
authors: Ichai
authors: Département d'Anesthésie Réanimation, Hôpital Saint-Eloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier Cedex 5, France; InsermU-1046, Université Montpellier I, Université Montpellier II, 34295 Montpellier cedex 5, France.
authors: Samir
authors: S
authors: Jaber
authors: Service d'Anesthésie et de Réanimation, AP-HM, Hôpital Nord, Aix Marseille Université, 13915 Marseille cedex 20, France.
authors: Marc
authors: M
authors: Leone
authors: Pôle Anesthésie Réanimation Douleur Urgences, CHU de Nîmes, place du Pr-Debré, 30029 Nîmes, France.
authors: Jean-Yves
authors: JY
authors: Lefrant
authors: Service d'Anesthésie Réanimation, Groupement Hospitalier Édouard-Herriot, 69003 Lyon, France.
authors: Thomas
authors: T
authors: Rimmelé
mesh_terms: D016223:Advance Directives / Q000331:legislation & jurisprudence*; D000368:Aged; D054869:Clinical Audit; D000066491:Clinical Decision-Making; D005260:Female; D005602:France; D019983:Guideline Adherence; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013997:Time Factors
keywords: End-of-life; Family communication; Withdrawing; Withholding