End-of life decisions in intensive care units:attitudes of physicians in an Italian urban setting

Abstract Objective: To assess the attitudes of physicians in Milan, Italy, intensive care units (ICUs) regarding end-of-life decisions. Design: Anonymous self-adminis- tered questionnaire. Setting: All20 ICUs in Milan. Participants: Phy- sicians employed in the ICUs. Measurements and results: The re- sponse rate was 87% (225 of 259). Eighty-two percent of respondents estimated that <10% of deaths in their ICU followed foregoing treat- ment, whereas 6% estimated that more of 25% deaths followed fore- going treatment. Male gender, long professional experience, and activity mainly in the ICU were significantly associated with greater willingness to forego life-sustaining treatments. Eighty-nine percent of respondents said ethical consultation on end-of- life decisions was never sought; 58% said they would not respect the ex- pressed desire of the patient to fore- go treatment; and 48% never noted the decision to forgo treatment on the clinical record. After a decision to withdraw treatment, 31% of phisicians said they maintained ongoing treatment, but withheld CPR for cardiac arrest; 47% considered withholding and withdrawing life support were not ethically equiva- lent. Conclusions: Most physicians considered that most ICU deaths were not the result of deliberately foregoing life support. Although the overall trend was to intervene mini- mally in patients’ dying, individual factors significantly influenced end- of-life decisions. Few physicians sought external ethical advice and decisions were entirely taken by the medical team. Direct involvement of family and treating physician was limited, and the expressed wishes of the patient were generally ignored.