Cuidados paliativos y medicina

Abstracto

Medical Futility and End-of-Life Decisions in Critically ill Patients:Perception of Physicians and Nurses on Central Region of Portugal

Ana Teixeira, Elisabete Figueiredo, João Melo, Isabel Martins, Cláudia Dias, António Carneiro, Ana Sofia Carvalho and Cristina Granja

Introduction: The Intensive Care Unit (ICU) is the setting where patients are given the most advanced life sustaining treatments. However, it is also the setting where death is common and end-of-life care is frequently provided. The aim of this study was to understand the reality of the decision making process on end-of-life in ICUs of several hospitals in the central region of Portugal.
Methods: A questionnaire to assess end-of-life decision making and attitudes towards medical futility in the ICU was developed. It comprises socio-demographic-professional variables and questions on end of life decision making process and medical futility, attitudes and believes. Between May and October 2010, 183 questionnaires were returned from a total of 235 delivered - 78% response rate.
Results: The 183 returned questionnaires included 147 nurses (80%) and 36 physicians (20%); 60% were female; median age was 39 years-old; 86% were catholic. Reasons pointed out for excessive/unjustified treatments, by more than half of nurses and physicians, included non-acceptance of treatment failure, insufficient training on ethical issues, difficulty on accepting death, incorrect evaluation on clinical condition; difficulties in communication were pointed out by a third of nurses and physicians. Fifty four percent of nurses and 74% of physicians have never had any training or education concerning medical futility and end-of-lifeissues. Seventy-seven percent of nurses and 69% of physicians considered that they felt the need of training/education on medical futility and end-of-life issues: 64% of physicians because of control of symptoms and 43% of nurses because of the need of a better communication among nurses, physicians and patients’ family (i.e. physicians vs nurses- physicians vs families-nurses vs families). There were statistically significant differences between nurses and physicians on answers concerning whom should be and who is, in fact, involved on end-of-life decisions. To reduce the occurrence of medical futility, strategies that were pointed out included mainly education and training and enhancing communication inside the ICU team and with the families.
Conclusion: This study has shown problems of communication, namely discrepancies of opinion between nurses and physicians and discrepancies between on whom should be and whom is in fact involved on end-of-life decisions. These discrepancies, together with the lack of education/training were the main findings that might explain difficulties found in the decision making process. Strategies to find an improvement in communication and to narrow the span between what is thought to be the correct choice and what is actually done are thus warranted.