Inlfuencing Factors And Status Of Forgoing Life-Sustaining Treatment For End-stage Patients In ICU

Objective:With the development of modern medicine and the change of the disease spectrum,people recognize that even with the aid of high technology and ICU(Intensive Care Unit)monitoring equipment, curing of many diseases still beyond human ability. A largenumber of patients at their life-ending stage may choose to give up the life-sustainingtreatment in varying degrees because of physical, spiritual suffering or economicconditions Currently, there are operational guidelines regarding giving up life-sustainingtreatment for end-stage patients in ICU in many western countries, but there is no suchunified and standardized document in China under our cultural background. For thisreason,this paper studied the status of decisions making of giving up for life-sustainingtreatment of end-stage patients in ICU, the attitude and experience of family members andmedical staff in light of giving up of the life-sustaining treatment to explore the relatedfactors of decision making in giving-up the life-sustaining treatment, to provide thesustaining for the ICU medical staff in the face of end-stage patients and their familiesfrom the aspects of theory, attitude, care programs and health education and to improvethe quality of death on ICU patients at end-stage, as well as to provide a theoretical basisfor the development of hospice care practice in the ICU.Methods:①This research exploded the status of giving up life sustaining treatment of ICUend-stage patients in different countries and regions such as the United States, Britain, Italy,Sweden, France, the Netherlands, Taiwan and Hong Kong through the literature study.Based on this, the initial draft of the basic entry for the case review index system had beenestablished.②Experts discussion Experts including one senior doctor and three nurses fromICU,two in the from hospice palliative care, one from ethic committee,one statisticianwere invited.Focus group method was employed for expert’s discussion. Eventually aCase Review index system and qualitative Interview outline for interviewing ICU doctors,nurses, and family members were established.③Convenience sampling was used to conduct case review for the surgical ICUadmission cases from the period of the August,2010to the August2011in3selectedtertiary general hospitals. The ratio of patients giving up the life-sustaining treatment in ICU was investigated and whether there was a decision-making to give up life-sustainingtreatment for the patients before death and whether there was significant differences inlife-sustaining treatment practice before and after the giving-up life-sustaining treatmentand logistic regression analysis was used to analyze the related factors of giving-up the lifesustaining treatment.④A purposive sampling was used to conduct the qualitative interviews for the ICUmedical staff and family members of patients from3selected tertiary hospitals. Theattitudes and experiences of the health care workers and family members of patients atend-life stage regarding giving-up life sustaining treatment were surveyed. Combiningresults of the qualitative study and case review analysis, targeted recommendations andcountermeasures of end-stage medical care were raised for end stage ICU patients in ourcountry.Results:①The studies have shown that the mode of traditional treatment with disposal of allcosts to rescue life and active treatment till the end for ICU patients at end-stage have beenreplaced gradually with medical practices of respecting for the quality of life, avoidingprolong a meaningless life, alleviate pain on patients.②There are two medical treatments modes for the ICU end-stage patients: activelife sustaining treatment and the giving-up life-sustaining treatment (including notreatment, withdrawal treatment).③Research findings showed that there were137patients with decisions to give upthe life sustaining treatment. Of which,99.28%consent were signed by, family members,only one case was signed by the patient with no medical staff signed. Multivariate logisticregression analysis found that the effected factors to sign a giving-up the life sustainingtreatment for ICU patients with end-stage were the patient’s age, place of residence,hospitalization costs.④Among the giving up the life-sustaining treatment measures,invasive treatmentmeasures were chosen by the most family members of patients, such as choosing to giveup CPR accounted for14.49%, to give up defibrillation accounted for12.62%, only19.63%chose fluid maintenance and34.58%of them gave up all treatment measures.⑤The outcome of patients giving-up life sustaining treatment was as following:patients died in the ICU accounting for26.28%. Patients voluntarily discharged for homeaccounting for72.26%, among which, there were relatively a larger proportion of patients actually had died upon leaving the ward. But these cases were dealt as same as thetreatment of voluntarily discharge based on the customs and the request of their families.⑥In the death cases, there were significant differences between the patients in rescuegroups and non-rescue group regarding24hours before death life sustaining treatment inthe use of vasoactive drugs, invasive mechanical ventilation, anticoagulants, bloodtransfusion, external cardiac massage, defibrillation, resuscitation drugs, cardiacpacemakers and other aspects. The ratio of using the above mentioned treatment in therescue group was much higher than that in the non-rescue group.⑦The experience and attitudes of medical staff in ICU regarding giving-up thelife-sustaining treatment grouped into eight themes in the four aspects. Medicine aspectsincluding:(1) medical standard for giving up the treatment;(2) the diagnostic criteria forbrain death; Ethical aspects:(1) guilt;(2) The sanctity of life; Legal aspects:(1)Documents for standardizing the implementation give up treatment;(2) reliable legalprotection; Education aspect:(1) the necessity of death education;(2) Palliative Medicinetraining.⑧Reasons for family members of ICU patients at end-stage insisting on the continueactive treatment were the factors of economy, morality and death education.Conclusion:①In this study, the result of analyzing the ICU patients at end-stage will serve as aguidance for medical health care staff in the correct treatment when they encounter thetreatment of end-stage patients to reduce or avoid ineffective or futile treatment, to avoidthe waste of limited medical resources in China and to alleviate the burden of family andsociety, to improve the quality of death on ICU patients at end-stage, provide theoreticalreference for the development of hospice care the ICU.②The research shows that the ratio of signing consent for giving-up thelife-sustaining treatment for patients at end-stage before death in the ICU of Chinesemainland is less than that in western countries and other region such as Taiwan and HongKong This result is associated with the cultural background of the Chinese mainland andthe lacking of laws and regulations regarding to the withdrawal life sustaining treatmentand appropriate death education. The death education program should focus on theadvocacy and education on ICU medical staff and their patients’ families regarding givingup the life sustaining treatment. The Government and Heath management should establisha set of policy evaluation standards and legal norms for those ICU patients at end-stage without any treatment value and meaningless that will be performing the giving up the lifesustaining treatment. This will provide a practical theory of reference for improving thequality of end of life in the dying patients in ICU and the basis for the development ofhospice care in the ICU.