|Year : 2013 | Volume
| Issue : 3 | Page : 200-205
Limiting intensive care therapy in dying critically Ill patients: Experience from a tertiary care center in United Arab Emirates
Masood Ur Rahman1, Abuhasna Said1, Chedid Faris2, Mousab Al Mussady1, Amer Al Jundi3
1 Department of Critical Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
2 Department of Neonatal Intensive Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
3 Department of Pharmacy, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
|Date of Web Publication||1-Oct-2013|
Department of Critical Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai
United Arab Emirates
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Limitations of life-support interventions, by either withholding or withdrawing support, are integrated parts of intensive care unit (ICU) activities and are ethically acceptable. The end-of-life legal aspects and practices in United Arab Emirates ICUs are rarely mentioned in the medical literature. The objective of this study was to examine the current practice of limiting futile life-sustaining therapies in our ICU, modalities for implementing of these decisions, and documentations in dying critically ill patients.
Materials and Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients' baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected.
Results : The electronic medical records of 67 patients were reviewed. The commonest method of limiting therapy was no escalation 53.6%. Interventions were withheld in 41.5%. "Do not resuscitate" order was documented in only 16.3%. The commonest method of documenting limitation of therapy was discussion with the family and documenting the prognosis and futility of additional therapy (73.3%). Patients who died early (<48 hrs) compared to patients who died late (>48 hrs) of ICU admission received terminal cardiopulmonary resuscitation more frequently (P < 0.007), had less frequent prognosis documentation (P < 0.009), and had more vasopressors administered (P < 0.006).
Conclusion : Withholding therapy after discussion with the family was the preferred mode of limiting therapy in a dying patient.
Keywords: Intensive care unit, life-sustaining treatment, withdrawal, withholding
|How to cite this article:|
Ur Rahman M, Said A, Faris C, Al Mussady M, Al Jundi A. Limiting intensive care therapy in dying critically Ill patients: Experience from a tertiary care center in United Arab Emirates. Int J Crit Illn Inj Sci 2013;3:200-5
|How to cite this URL:|
Ur Rahman M, Said A, Faris C, Al Mussady M, Al Jundi A. Limiting intensive care therapy in dying critically Ill patients: Experience from a tertiary care center in United Arab Emirates. Int J Crit Illn Inj Sci [serial online] 2013 [cited 2019 Aug 24];3:200-5. Available from: http://www.ijciis.org/text.asp?2013/3/3/200/119201
| Introduction|| |
The important advances in life-support technology and critical care that enabled maintenance of vital functions have given the ability to support dying terminally ill patients with medical interventions, which though lifesaving, may result in prolonging inevitable death. Moreover, such advanced technologies may even prolong the dying process of patients for whom the possibility of surviving or regaining an acceptable residual quality of life is nil. It is a common practice in modern intensive care to limit or withdraw therapy in terminally ill patients to avoid the futile suffering of dying patients. Though practiced often, documentation of the limitation or withdrawal remains poor even in countries with legal and medical policy regarding limitation of therapy in dying critically ill patients. 
Despite the fact that such practices are acceptable from an ethical point of view, are common worldwide, and have been approved by the international scientific community, there is no formal do-not-resuscitate (DNR) policy in United Arab Emirates yet. , In addition, due to cultural and societal reasons,  end-of-life issues are not discussed beforehand despite the evidence from primary literature that showed that a large proportion of intensive care unit deaths are preceded by withholding or withdrawal of treatment based on clinical parameters to limit the treatment. ,,,,,,,,, Moreover, there is no concept of advanced medical directive yet in our society so, in most of the instances, intensivists have to discuss and document end-of-life discussion in an environment where there is no clear policy or legal frame work to guide them. Additionally, for patients who are terminally ill and present to emergency room (ER), physicians are forced due to fear of legal liabilities, or personal belief, to perform aggressive interventions including CPR and intubation in a patient whose chances of meaningful recovery are poor. It is also well known that the emergency department might not be an appropriate place to give end-of life care decision, subsequently; these patients will be shifted to ICU. 
Studies have shown that the culture can play a major role in degree of involvement of relatives and the frequency of withholding or withdrawal of end of life support.  Additionally, these decisions are difficult to take and depend on ethical issues and moral issues that are mostly related to the cultural values. 
The objective of this study was to examine the current practice of limiting futile life-sustaining therapies in our ICU and documentation in dying critically ill patients. We also compared the differences in life-sustaining interventions in patients who died early (within 48hrs) with patients who died late (>48 hrs) after ICU admission. We believe that the majority of patients who died in our ICU did not have a formal DNR order as there are no formal legal or medical guidelines to limit therapy in terminally ill patients at our institution. We also believe that discussion between the physician and the family and documenting poor prognosis is the commonest way of limiting therapy. In addition, we also believe that patients who die early (within 48 hrs) of admission to ICU tend to get more aggressive measures as physician-to-caregiver link will not be established yet in most of the cases.
| Materials and Methods|| |
The study was approved by the ethics committee at our hospital. The investigation was a single-center retrospective chart review of all patient who died (n = 67) during the period from Sept 2008 to February 2009 in our 20-bed mixed medical and surgical intensive care unit at our 450-bed government acute care hospital in the city of Al Ain, United Arab Emirates (UAE). Patients' baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw or not to escalate therapy including mechanical ventilation, vasopressor and hemodialysis were collected. Documentation of DNR, comfort care, and prognosis were also extracted from medical charts. Pair wise comparisons were based on independent student t-test for continuous data, Mann-Whitney U test for nonparametric data. Categorical data or proportions were analyzed using either the Chi-square test or the Fisher exact test when the expected frequency was <5. Descriptive statistics were calculated for all variables of interest. All tests were two-tailed and statistical difference was defined as a P < 0.05. Statistical analyses were carried out using SPSS for Windows. Limiting therapy referred to either withholding or "no escalation" of current therapy. Withdrawal of therapy was defined as the removal of a therapy that was started in an attempt to sustain life but has become futile and is just prolonging the dying process. "No escalation" referred to "no therapeutic escalation"" of the previously implemented interventions, while withholding was defined as the absence of further addition to already implemented therapies.
| Results|| |
In this retrospective study, the electronic medical records of 67 patients were reviewed. Patients' age, sex, admission diagnosis, and nationality are listed in [Table 1]. Majority of patients were males 61.2% (41/67) with mean age of 54.8 ± 22.8. Emirate Nationals formed the majority 50.4% (34/67). Commonest admission diagnosis was sepsis or septic shock 40.3% (27/67), followed by cardiac arrest and respiratory failure 19.3% (13/67) and 14.9% (10/67), respectively, while head trauma was the diagnosis in 10.4% (7/67). Cancer or hematological malignancy and coronary artery disease or congestive heart failures were pre-existing problems in 28.4% (19/67) and 26.8% (18/67), respectively. [Table 2] presents the past medical history of the studied patients who were admitted to our ICU.
Methods of limiting therapy [Table 3]
The mode of death was determined from documentation in the intensivists' progress notes. The commonest method of limiting therapy was no escalation and continuing with the existing therapy 53.6% (30/56). Feeding was withheld in only 11% (6/52) of patients. Interventions were withheld in 41.5% (22/53) while DNR was documented in only 16.3% (7/43). The preferred method of documenting limitation of therapy was discussion with the family and documenting the prognosis and futility of additional therapy 73.3% (44/60).
|Table 3: Outcome parameters for patients who died within 48 hrs of admission (early group) versus those who died≥48 hrs from admission (late group)*|
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Differences in interventions in early (<48 hours) versus late death (≥48 hrs) after ICU admission [Table 3]
Patients who died early received terminal CPR more frequently versus patients who died late (50% (13/26) vs. 18.4% (7/38); P < 0.007). Prognosis documentation was also less frequent in the early group (58.3% (14/24) vs. 87.2%; P < 0.009). Additionally, therapy was not escalated in fewer patient (28.6% (6/21) vs. 68.6% (24/35); P < 0.007). Furthermore, there was a statistically significant difference in vasopressors administered between both groups (87% (21/24) 66.7% (26/39); P < 0.06) in favor of the early group.
| Discussion|| |
While limiting life-support interventions is common in western societies, ,,,,, medical literature is sparse and variable in regards to this issue in the Middle East. ,,,, To our knowledge, this article reports the results of the first UAE observational study concerning documentation of the decision to withhold or to withdraw life-sustaining interventions in dying patients in an intensive care unit.
Our review demonstrated that intensivists at our institution, in a setting with no clear legal framework or hospital based policy, continue to practice limitation of medical therapy in terminally ill futile medical cases. There are some interesting findings in our review; DNR order was rarely written. There could be several reasons for this finding. First, DNR holds no legal standing or recognition at our institution, which may reflect the reluctance of physicians to record their decisions under such circumstances. Second, when CPR is offered as an intervention there may be a false perception among family members, who are non-medical entities, of cardiopulmonary resuscitation (CPR) being a lifesaving intervention though it is not associated with a meaningful survival benefit in terminally ill patients. , Third, there could be deliberate evasion by physician at our institution to use this term. The avoidance could be due to lack of rapport, or comfort level of physician in addressing end of life with patient family or due to personal belief of physician in equating denying of therapy to euthanasia. Lastly, fear of legal implication of not doing CPR in case of cardiac arrest is also possible.
Prognosticating the patient outcome to the family and emphasizing the lack of meaningful benefit of any further medical therapy seems a more acceptable and is a common practice in our intensive care unit. We believe intensivists are more comfortable in using these wordings as it does not address limiting therapy and indirectly gives the physicians the authority to decide which therapy to use to keep the patient comfortable, which can mean limiting or withholding therapies considered to be of no meaningful benefit to the patient. In addition, the family is exempted from the burden of taking the decision of limiting therapy for their loved ones, which in the long run may cause inner guilt, of not doing enough, for the caregiver. 
Based on our analysis, DNR orders and comfort care were written more frequently in patient who died late (>48 hrs) of ICU admission. We hypothesize that intensivists are comfortable by this time frame to communicate prognosis and limiting therapy to family, as they have created a rapport between the patient's surrogate decision makers. Moreover, the medical condition of the patient will be clearer from a prognosis point of view, especially in the post cardiac arrest scenario;  this can decrease the distress experienced by both healthcare providers and patients' family members when transitioning the patient to palliative support through discontinuation or no escalation of all unnecessary intervention, monitoring devices and tubes.
Documentation of the discussion is something lacking even in developed countries with legal system supporting DNR decision.  In our ICU, documentation of prognosis discussion was done in majority of the cases. There was no difference between early and late death in terms of discussion of prognosis with the family. However, documentation of prognosis was written significantly more in patients dying late.
Islamic bioethics is based on Shariah (Islamic law), which is itself based on the Quran (the Holy Text believed by Muslims to be the direct word of God), the Sunnah (the Islamic law based on the Prophet Muhammad's words or acts), and the Ijtihad (the law of deductive logic). 
In Islamic culture, withholding therapy seems to be a more acceptable mode of limiting futile therapy when based on the physician advice and consensus of family members. ,, In our study, withholding was the preferred method of limiting end-of-life interventions. The process of the withdrawal or withholding of life support frequently involves several discussions with family as treatment goals are readdressed especially when the chances of survival decline. Once the decision is directed to withholding therapy, life support is made and the goals of therapy changes from attempted cure to providing comfort measures. Therefore, the use of aggressive intervention including dialysis, inotropic support, and mechanical ventilation would have to be justified in terms of providing comfort. If the treatment goal is to provide comfort as death occurs, perhaps these modalities may prolong the dying process. However, an acceptable goal of therapy for one physician may not be considered acceptable for another. This even may vary among same the specialty, or from one specialty to another. ,,
Based on our results, the vast majority of terminally ill patients received vasopressors and mechanical ventilation. Due to personal belief or fear or legal repercussion, intensivists would feel more comfortable to address limitation of therapy once the patient is intubated or on vasopressor therapy than setting limits or convincing the family on limitation of therapy while patient has not been offered invasive procedure. Additionally, it takes away a burden of guilt of not doing enough for the patient especially if the decision was unilateral. Moreover, continuation with aggressive therapy can be based on family wishes especially when communication of poor outcome and lack of meaningful; benefit of therapy is inadequately communicated. Another important factor may be that family members are offered options to forego versus aggressive intervention including intubation and CPR for the first time in a pre- arrest scenario, which frequently leads family member to opt for aggressive intervention hoping the intervention would save their loved one. Although it is well known that CPR in an intensive care setting is a futile exercise, the consequences would be advanced airways placement and vasopressor therapy that prolong the natural dying process and result in undue suffering for dying terminally ill patient.
"No escalation" of therapy was documented in almost half of the cases. We did not look into therapies that were not escalated. "No escalation" seems to be the favored mode of limiting therapy in Middle Eastern ICUs. , Withdrawal, though practiced in various hospitals worldwide, is not an acceptable strategy among family members and physicians.
Our analysis also showed that almost one third of patients who died had terminal CPR especially if the death occurred early (first 48 hrs) of ICU admission. We believe that a significant number of these CPRs were futile. Despite that the prognosis of the dying patients and subsequent discussion with the family members were documented, half of the patients in early death group received CPR. The reason behind that was not documented; it was not clear if it was due to insistence of family members to perform CPR or due to the physician's belief or hope that patient has a chance for survival. Other causes that can be attributed to performing this futile CPR can include the fear of physicians of considering the decision to be unilateral, lack of legal protection versus the legal right of the patient's competent autonomous person, unclear plan for the patient, and even lack of communication between physician to on call team about the prognosis of the patient.
Our study is the first study in United Arab Emirate looking at the documentation of end of life and prognosis in terminally ill patients. However, it has several limitations. It is a retrospective chart analysis that can be biased by inadequate documentations. The intensity and length of CPR was not documented. Additionally, the study was also a single-center study performed over only six months. The sample size was also small and has the potential for type I or II errors.
End-of-life decisions will continue to be a growing need in the ICU as medical technologies enhance the ability to prolong life. Documenting the care provided to patients and their families during withholding of life support is part and parcel of medical care. In a place with no clear policy or guidelines on limitation of therapy, it is understandable that such documentation does not always occur. Despite of lack of agreement on medical terminologies for limiting therapies in dying critically ill patients, intensivists at our hospital continue to limit therapy in after a frank informed discussion with family members and documentation of poor prognosis.
At our intensive care, physicians make treatment decisions in consultation with other physicians. When patients' family members are involved, physicians are most commonly the initiators of discussions about end-of-life treatment issues and their opinion often predominates.
Relationship and communication between patients and their families, between patients and patients' families and the healthcare team, and between members of the healthcare team are the key elements to enhance the end-of life decision making.  We believe that legal systems, medical societies, and governing bodies in United Arab Emirates need to decide that it is about time to formulate a legal policy on end-of-life management of dying patients, as we are providing futile care in a significant number of patients whose poor outcomes can be predicted.  Due to the complexity of ICU situations, this policy will be based on presumed prognosis for favorable outcome and interpretation of patient, family, and even physician wishes. Implementing such a policy will decrease the distress experienced by both healthcare providers and patients' family members, aids in balancing aggressive care with realistic expectations, and makes the ICU a caring place in which to die. I think our work is still in progress.
| Conclusion|| |
Withholding therapy was the preferred method of limiting end-of-life interventions. Cultural and religious beliefs and the lack of guidelines and official national laws could explain the ethical limitations of the decision-making process reported in this study. Formulating a national policy based on physicians' attitudes and the perceptions of patients and families is necessary to clarify the legal position about end-of-life decisions in ICU and will decrease the distress experienced by both healthcare providers and patients' family members when such decisions cannot be avoided.
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[Table 1], [Table 2], [Table 3]
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