The Durban World Congress Ethics Round Table IV: Health care professional end-of-life decision making

Journal of Critical Care 30 (2015) 224–230

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The Durban World Congress Ethics Round Table IV: Health care professional end-of-life decision making Gavin M. Joynt, MBBCh, FFA(SA)(Crit Care), FHKCA (IC), FCICM a,⁎, Jeffrey Lipman, MBBCh, DA, FFA(SA)(Crit Care), FCICM, MD b, Christiane Hartog, MD c, Bertrand Guidet, MD d, Fathima Paruk, MBBCh e, Charles Feldman, MBBCh, DSc, PhD, FRCP, FCP (SA) f, Niranjan Kissoon, MD g, Charles L. Sprung, MD, MCCM, FCCP h a

Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong Royal Brisbane and Women's Hospital, Herston, Australia c Center for Sepsis Control and Care, University of Jena, Jena, Germany d Hôpital Saint-Antoine, Paris, France e University of the Witwatersrand, Johannesburg, South Africa f Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa g BC Children's Hospital, University of British Columbia, Vancouver, Canada h Hadassah Hebrew University Medical Center, Jerusalem, Israel b

a r t i c l e

i n f o

Keywords: Surrogate Intensive care Ethics Futility Terminal illness Definitions

a b s t r a c t Introduction: When terminal illness exists, it is common clinical practice worldwide to withhold (WH) or withdraw (WD) life-sustaining treatments. Systematic documentation of professional opinion and perceived practice similarities and differences may allow recommendations to be developed. Materials and methods: Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress that took place in Durban (2013), with an interest in ethics, were approached to participate in an ethics round table. Key domains of health care professional end-of-life decision making were defined, explored by discussion, and then questions related to current practice and opinion developed and subsequently answered by round-table participants to establish the presence or absence of agreement. Results: Agreement was established for the desirability for early goal-of-care discussions and discussions between health care professionals to establish health care provider consensus and confirmation of the grounds for WH/WD, before holding formal WH/WD discussions with patients/surrogates. Nurse and other health care professional involvement were common in most but not all countries/regions. Principles and practical triggers for initiating discussions on WH/WD, such as multiorgan failure, predicted short-term survival, and predicted poor neurologic outcome, were identified. Conclusions: There was majority agreement for many but not all statements describing health care professional end-of-life decision making. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Approximately 10% to 30% of all emergency admissions to intensive care units (ICUs) will die in the ICU; [1-3] and, therefore, management of the dying process is a necessary skill for all ICU health care professionals. Life-support technology has advanced, so that it is now possible to maintain vital organ function, despite the realization that a return of the patient to reasonable health and an acceptable quality of life are no longer possible. When a return to reasonable health is no longer possible, it has become common clinical practice worldwide for ICU staff to limit life-sustaining treatments (LSTs) by withholding (WH) or withdrawing (WD) LSTs [4-12]. There are, ⁎ Corresponding author. Tel.: +852 26322738; fax: +852 26372422. E-mail address: [email protected] (G.M. Joynt). http://dx.doi.org/10.1016/j.jcrc.2014.10.011 0883-9441/© 2014 Elsevier Inc. All rights reserved.

however large differences in the practice of WH/WD in different parts of the world as evidenced by responses to several surveys that have explored physicians' practice and ethical views on the subject [13-20]. This self-reported variation in the pattern of practice of health care practitioners has been confirmed by observational studies that also demonstrate regional variations in practice [4-12]. Although guidelines for some jurisdictions do exist, [21-25] and are often useful, they sometimes lack sufficient detail to guide daily practice and seldom consider the variability inevitably introduced by cultural and regional differences. Although cultural and social differences are slow to evolve, people in the modern world migrate in large numbers, with ease and over great distances. It is thus important that ICU health care professionals are aware of similarities and differences in international end-of-life practice and expectations [26-28].

G.M. Joynt et al. / Journal of Critical Care 30 (2015) 224–230

The decision to initiate the process of WH/WD for a particular patient is a complex one and one that involves several stakeholders. To begin with, it requires recognition that WH/WD is potentially justified, followed by a process to confirm the appropriateness of WH/WD. Lastly, it must be demonstrated that the decision to proceed is in the best interests of the patient himself/herself. This article will focus specifically on the initial part of the end-of-life process, that is, making the decision to proceed to WH/WD discussions with the family. With information drawn from the results of an international meeting of experienced clinicians with an interest on end-of-life care, we have documented similarities and differences in the way the above process is managed around the world, and where sufficient similarities were shown to exist, have developed statements of general agreement. 2. Methods Speakers from the invited faculty list of the World Federation of Societies of Intensive and Critical Care Medicine Congress, held in Durban September 2013, were approached by the conference scientific convener to participate in the ethics round table. All round table participants had a known interest in ethics. Round table participants were asked to identify what in their opinion constituted the 3 most pressing specific worldwide ethical issues that the group should address. Most responded that end-of-life issues, including WH and WD LSTs constituted the most important issue. Seventy questions related to end-of-life care in ICU were sent to participants. Before the round table discussion held in Durban, participants were asked questions by e-mail circulation to determine local practice in their hospitals and countries, in relation to the clinical practice of end of life. There were 20 responses with similarities and variations from different countries that seemed the most interesting (decision by author CS). The summary of these responses was sent to all participants by e-mail before the face-to-face meeting. Respondents were asked to identify the most important and relevant topics from this list and to then prepare for face-to-face discussion at the Congress. The 5 topics with the greatest clinical importance and differences between centers and countries were chosen by agreement at the face-to-face round table discussion. They included questions related to WH and WD LSTs at the end of life for age, health care professional end-of-life decision making, patient/family end-of-life decision making, how to withdraw mechanical ventilation, and differences between WH and WD LSTs. The focus of this article is to describe the process of health care professional end-oflife decision making. To further define key issues in this process, discussion in Durban identified the following key questions related to the focus of this manuscript: (1) Is there a need for consensus by any, some, or all stakeholders when making decisions to proceed to WH/WD? (2) If consensus is required, is there or should there be a specific sequence by which ultimate consensus is achieved among all stakeholders? (3) Should goal-of-care discussions routinely take place, and when should they be initiated? (4) Which parties are or should be responsible for the initiation, discussion, and decision-making processes? (5) What “general principles” justify the decision to consider WH/WD life support? (6) What “specific clinical factors” trigger decisions to proceed to discussions and decisions on WH/WD? After the meeting, questions were developed to provide an overview of current practice and opinion related to the questions. Questions were tested for validity by giving all participants an opportunity to comment on, add, or change questions (using e-mail). This resulted in a final set of questions that were answered by round table participants. A total of 76 questions were finalized, using a Likert scale format (strongly agree,

225

agree, neutral, disagree, and strongly disagree), with a free-text options for comment. The answers that specifically relate to the stated questions that are the focus of this report are section II, health care professional end-of-life decision making. Questions from this section have been renumbered from 1 to 30 for clarity (Appendix 1). 3. Results A list of round table participants can be found at the end of the manuscript. The final set of questions that was developed and then answered by e-mail circulation can be found in Appendix 1, and results are presented in the order of the goals set out in the methods. The responses to the final questions developed by the round table group are shown in Tables 1 to 3. To simplify the presentation of results, the Likert scale format (strongly agree, agree, neutral, disagree, and strongly disagree) was simplified by grouping strongly agree and agree and strongly disagree and disagree. Results to questions are presented in order, corresponding to the key questions stated in the methods. (1) At the original round table discussion, it was evident that there were differences in practice relating to the need for consensus among professional health care providers before engaging the family in discussions. Therefore, to characterize the process before a formal family/surrogate discussion, the following considerations were explored: question 1 explored the possibility of discussing patient preferences regarding WH/WD in general (statement A) or general values, goals, and preferences without specific mention of WH/WD (statement B). Table 1 documents participant responses on these key issues to be addressed before holding a WH/WD discussion with the family and favored the need to explore patient preferences and values before WH/WD discussions. (2) Question 1 (statements C-F) explored the requirement, if any, for reaching a medical consensus before having a WH/WD discussion with the family. Participant responses are documented in Table 1 and generally favored the need to achieve medical consensus before family discussion. Table 1 Participant views on key issues to be addressed before holding a WH/WD discussion with the family, including early goal-of-care discussions Agree Neutral Disagree All 1 Before WH/WD discussions with the family 1A Initial discussion—explore patient WH/WD preferences 1B Initial discussion—explore patient values, goals on WH/WD 1C Hold discussions with the primary care physician 1D Discussions with other intensivists 1E Discussions with nursing staff 1F Discussions with both physicians and nurses in ICU 2 Goal-of-care discussion 2A Early goal-of-care discussion—general medical issues 2B Early goal-of-care discussion—info on WH/WD issues WH/WD discussions should occur in response to: 3 Patient/family requests (including advance directives) 4 Physician requests 5 Nurse requests 8 9

Reported participation ICU nurses in ICU rounds Routine formal discussions on WH/WD with nurses

17

1

3

21

18

2

2

22

19

3

0

22

20 19 19

1 2 2

1 1 1

22 22 22

17

3

2

22

8

8

6

22

19

0

3

22

20 16 Agree 18

1 3 Neutral 2

1 3 Disagree 2

22 22 All 22

16

0

6

22

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Table 2 Statements of general principles underlying the WD and WH of life support Principles—justification for triggering WH/WD 10A 10B

10C.1 10C.2 10C.3 10C.4 10C.5 10C.6

Agree Neutral Disagree All

Principles justifying WH/WD Patient's best interest not served by LST Insufficient net medical benefit gained by LST The above conditions are met when: With LST b3-month survival With LST b1-month survival With LST b2-week survival With LST less than a few days' survival ICU burden outweighs likely length of time of survival ICU burden outweighs likely future quality of life

19 21

0 1

3 0

22 22

12 14 17 21 18

3 5 2 1 3

7 3 3 0 1

22 22 22 22 22

17

4

1

22

(3) Question 2 explored the important option of implementing an early goal-of-care discussion, and whether this discussion should specifically include information relating to WH/WD of life support. Results in Table 1 generally supported the need for early goal-of-care discussions. (4) Questions 3 to 5 explored responses on who should trigger a WH/WD discussion, and questions 6 to 9 explored the mechanisms by which nurses were included in the consensus process, if at all. A general but not unanimous agreement existed to involve other health care workers in WH/WD discussions (Table 1). The free-text answers to question 6 were collated. In answer to question 6, most participants stated that nurses' opinions were routinely solicited on ward rounds (n = 15). Three participants reported the use of formal multidisciplinary meetings as the mechanism for inclusion of nurses in the decision-making process. One participant (from Asia) indicated that nurses had no role in the WH/WD process. In answer to question 7, the communication process used to achieve consensus with various parties, including nurses and other health care professionals was varied. Mechanisms included informal

Table 3 Participant's reported likelihood of usng specific practical triggers that may contribute to the decision to discuss WH/WD LST

11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Practical triggers for WH/WD decisions

Always triggers

Usually triggers

Never triggers

All

Known advance directive Family request Irreversible condition Unsurvivable injury Brain injury—unclear outcome Brain injury—poor outcome and dependent Brain injury—minimally conscious state MOF—1-2 organs MOF ≥3 organs for ≥3 d MOF ≥3 organs for ≥7 d Nonbeneficial therapy Poor ICU survival Terminal illness Poor quality of life Severe illness Age N80 y

14 16 10 18 8 10

7 4 9 4 11 7

0 2 3 0 3 5

21 22 22 22 22 22

17

3

2

22

0 4 7 14 8 15 4 1 3 Yes 14

6 9 12 7 14 3 14 6 7 No 8

16 9 3 0 0 4 4 15 11

22 22 22 21 22 22 22 22 21 All 22

Strongly agree 18

Neutral

Strongly disagree 2

Total

27 Are there universally accepted triggers?

28 Should we use triggers as above? MOF, multiple organ failure.

1

21

discussions on ward rounds, formal scheduled multidisciplinary meetings, informal “huddles” of involved staff, telephone consultations with relevant individuals, and e-mail communications. (5) Question 10 explored responses to statements describing the general principles supporting WH/WD decisions and that justify triggering a family conversation. Views on relevant general principles underlying WH/WD and justifying the reason for the discussion of WH/WD with the family are reported in Table 2. (6) Questions 11 to 28 explored responses for specific clinical factors that may potentially trigger the decision to discuss WH/WD. Table 3 shows participant views of their likely use of specific practical triggers to inform the decision to discuss WH/WD LST. All disagreements were examined to establish whether they were accompanied by a free-text explanation. Notable free-text comments accompanying responses that were considered outliers are summarized below and grouped by region: • Participants from China indicated strongly that nurses took no part in end-of-life decisions. Participants from Korea indicated that nurse opinions were very rarely expressed. Furthermore, that the elderly seldom discussed end-of-life issues and as a result of advance directives were almost never available. • Regarding early goal-of-care discussions, most participants indicated that they were desirable; however, participants from China and Korea more strongly indicated that the issue of WH/WD should be avoided in the early stages of admission. • Participants from the Middle East indicated that local laws, hospital policy, and religious issues may restrict end-of-life care practice and should be taken into consideration. Other relevant free-text explanations that explained specific disagreements are provided in the discussion. In answer to question 29, all but one of the participants reported working in a “closed” ICU environment, where the resident specialist intensivists carried ultimate responsibility for patient care in the ICU. There were no specific responses to question 30 indicating the need for the addition of further questions. A list of generally agreed statements, derived from the deliberations, is provided in Table 4. 4. Discussion Broad agreement existed for the principle that, before a WH/WD discussion with the family/surrogate, discussions with relevant intensive care physicians, primary care physicians, and nurses should take place. The intention of these discussions is to establish consensus that a WH/ WD conversation with the family is appropriate, and decisions to subsequently initiate WH/WD would be reasonable. This approach may serve some important purposes. Firstly, prognostic certainty is difficult to achieve [29]; and, therefore, a broad agreement by competent and knowledgeable medical staff that prognosis justifies WH/WD is one method to enhance diagnostic accuracy, improve the sense of security in the diagnosis, and reduce stress [30]. Secondly, it may increase the objectiveness of the opinion when it is made by ICU physicians other than the attending physician alone [31]. Thirdly, it should ensure that surrogates receive a consistent message regarding WH/WD and avoids the potential risk of treatment team disagreements being communicated to the family, potentially causing confusion and loss of trust [32]. Obtaining treatment team consensus before the initiation of WH/WD discussion with the patient/surrogate was considered important. Interestingly, although some published guidelines imply the need for a broad medical consensus during the process of WH/WD [30,33], others make no reference to this aspect of decision making [21]. It has also been shown that lack of agreement on end-of-life decisions between the primary ICU medical team and other involved physicians may occur in up to 30% of cases and in up to 20% of cases with nurses [34]. It should be noted that 1 participant disagreed with the need for nursing consensus,

G.M. Joynt et al. / Journal of Critical Care 30 (2015) 224–230 Table 4 Durban (2013) Round Table—statements of general agreement 1. Knowledge of local, cultural, and religious practice and expectations as well as local legal restrictions should inform individual practice. These considerations are applicable worldwide but may be particularly relevant in the Middle East and Asia and when treating patients originating from these regions. 2. Goal-of-care discussions should generally occur early (within 48 h) after the patient's admission to ICU. Care should be taken to specifically address WH/WD in appropriate circumstances, for example, in patients with a very poor prognosis, or if the surrogate/patient requests such a discussion. Special sensitivity should be exercised when interviewing certain patients/surrogates, eg, in China and Korea, where early end-of-life discussions may be considered inappropriate. 3. Physicians are the most likely to initiate discussions that may lead to WH/WD decision-making processes. It should, however, also be recognized that the wishes of patients themselves through advance directives and families through verbal or written requests have the right to trigger WH/WD discussions. Nurses and other health care workers may trigger discussions among the medical health care team that may lead to WH/WD decision-making processes. In some parts of the world, eg, China and Korea, nurse involvement in end-of-life decisions is not expected. 4. When possible, treating ICU physicians and other specialty medical physicians should reach consensus that a WH/WD discussion is reasonable before formally starting a discussion with the patient/surrogate. In most parts of the world, nurses and other health care staff who are meaningfully involved in the patient's long-term care should also be consulted. In some parts of the world, eg, China and Korea, nurse involvement in end-of-life decisions is not expected. 5. Consensus regarding the decision to trigger a WH/WD discussion is usually reached by discussion between relevant health caregivers on routine daily ward rounds. Additional formal discussion forums can be scheduled if necessary, for example, in difficult or contested cases. 6. The decision to trigger a discussion of WH/WD LST should be made based on the principle that the patient's best interest is no longer served by LST, that occurs when sufficient net medical benefit cannot be achieved by ongoing LST (ie, nonbeneficial therapy). This condition is met when the burden of ongoing treatment outweighs the net health benefit that the patient is likely to derive in terms of length of time of survival, or quality of life. Quality of life should be determined by appropriate patient/surrogate consultation. 7. Although no universally agreed triggers should be prescribed, practically, the following may serve as triggers for initiating WH/WD discussions with the patient/surrogate. A WH/WD discussion: a. May be considered when survival would be expected to be b1-3 mo. b. Should be considered when survival would be expected to be b2 wk. c. Should always be considered when survival would be expected to be less than a few days. d. Should usually be considered when multiple organ failure (three or more organs for 7 or more days, despite therapy) exists e. Should usually be considered when very severe brain injury (with poor long term outcome eg, minimally conscious state) exists f. Should always be considered when, in the health care team's opinion: i. The patient is receiving nonbeneficial therapy ii. The patient has a nonsurvivable injury 8. Neither age alone, nor severe illness should be considered a sufficient trigger to initiate WH/WD discussions.

with the explanation that, in his country in Asia, nurses did not participate in WH/WD decisions and would not expect to participate in such decisions. A member from Asia also expressed a physician consensus decision would reduce the chance of error and legal challenge, a known concern for ICU clinicians in certain Asian countries [20]. It was generally agreed that early goal-of-care discussions (within 24-48 hours of admission) focused on prognosis, and potential outcomes were appropriate. The second statement explored the desirability of specifically discussing WH/WD at this time. Comments explaining disagreement with this approach included the need to avoid an unnecessary discussion of WH/WD in patients with a good prognosis. Early goal-of-care discussions have been increasingly investigated and recommended as a desirable practice [30,35,36]. Although the timing and nature of goal-of-care discussions resulted in some interesting and diverse responses, most believed that such conversations should take place early, although several members would limit such meetings to only those with a predicted poor outcome. The major concern was the perceived potential to undermine patient or family confidence by discussing WH/WD too early. This may be particularly true in Asian countries, where discussion of death may be considered rude or even dangerous by inducing future “bad luck” [37] and

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undermine the filial duty of children to protect elders and parents [38]. Others indicated a benefit to early meetings discussing goal-of-care expectations, even if this is to confirm a hopeful prognosis. Subsequent goal-of-care conversations may be then used to discuss WH/WD issues and may benefit subsequent communication by the earlier establishment to good relationships with the patients/surrogates. It was agreed that a WH/WD discussion with the family should follow a request from the patient, surrogate, or if indicated in an advance directive. Few disagreements by round table members with the statement were recorded, and it was noted in corresponding written explanation that requests from family or nurses should only trigger discussions with the surrogates, with an intention to proceed to WH/WD, if supported by physician consensus. Thus, the appropriate response to all requests from all stakeholders should be a health caregiver discussion, with the goal of evaluating the merits of the request, before a formal WH/WD discussion with the family. The usual method for reaching health caregiver consensus was face-to-face discussion, rather than phone calls, formal meetings, or written consultation. This discussion invariably took place on scheduled morning meetings or ward rounds and included physicians, nurses, and occasionally, other involved parties, such as physiotherapists and social workers. The exception was Mainland China, where the discussion was reported to only involve physicians. Some units reported the use of informal discussions or ad hoc dedicated meetings to discuss goals of care, particularly in difficult cases. No participant mentioned the need to consult an ethics committee at this stage. There was general but not universal agreement for the principles that underlie the decision to consider WH/WD life support. Specifically, most participants agreed that, in “The treating physician's opinion, the patient's best interest is no longer served by ongoing LST” was a basis for initiating WH/WD discussions. Comments accompanying the disagreeing responses stressed that subsequent decisions to take action should always follow discussions with surrogates and the wider health care team and not only result from the opinions of the treating physician, whose religious or cultural values might be different than the patient's. Disagreement in 1 case was explained by an expression of “legal concerns” relating to limiting LST in an Asian country. The statement “The patient's best interest is no longer served by LST, when sufficient net medical benefit cannot be achieved by ongoing LST” received strong support, with only a single expression of disagreement being recorded. This statement and the conditions under which it would be met were considered the basis for determining that treatment was “nonbeneficial” and could therefore trigger discussions to WH/WD LST. To try to develop a practical expression of what the above statement of “sufficient net medical benefit” may mean in terms of length or quality of survival, members were asked to respond to some statements quantifying length of survival. Members were progressively more likely to consider length of time of survival as a trigger to initiate WH/WD discussions, as the patient's predicted length of survival decreased. No members disagreed that a predicted length of survival less than a few days would meet the principle requirement to trigger a WH/WD discussion. This trend would seem to reflect the likely wishes of patients. Previous surveys have indicated that a majority of patients would accept ICU care for survival times of as little as 1 month [39]. It is important to recognize that, in individual cases, “after” a WH/WD discussion with surrogates/patients, continuing LST to reach agreed goals of care may remain justified, despite only a few days of anticipated survival. This is because net medical benefit implies a cost and a benefit assessment; and in each case, the “cost” of ICU care must be weighed against the medical benefit gained. Length of survival only quantifies potential benefit, the cost being the individual patient's perception of the burden of ICU care. The patient's and surrogate's view of the burden of ICU care may relate to many factors such as current and future physical pain and discomfort, mental anguish, and even monetary cost in some instances. Lengthy survival with a poor quality of life may be realistically not considered to be a benefit by individual patients. Nevertheless, these factors can only

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be reliably ascertained by the initiation of an open and honest goal-ofcare discussion. In free-text responses, the opinion was repeatedly expressed that this principle of balancing cost and burden should ultimately be confirmed by the patient's or surrogate's expression of their perception of the “net balance of benefit.” There was strong agreement by participants with the statements that health burdens should be weighed against benefit in terms of both length of time of survival and expectation of future quality of life. In an attempt to provide some practical guidance, a number of triggers that may provide grounds for initiating a WH/WD discussion were proposed. To the authors' knowledge, this is the first time that specific clinical triggers have been suggested and their potential acceptability to clinicians assessed. Multiorgan failure (involving ≥ 3 organs and 1-week duration) and severe brain injury (especially predicted minimally conscious state or neurologically dependent outcome) were considered reasonable triggers by the large majority. There is evidence for increased mortality in patients meeting the above organ failure criteria [40-42]. Despite evidence that the incidence of WH/WD is independently associated with advancing age, [43,44] age alone even when relatively extreme (N 80 years old) was not considered an appropriate trigger by most round table members. This view by the round table group may be supported by recent data indicating a good self-reported quality of life by elderly ICU survivors [45,46]. Advance directives and general assessments, such as unsurvivable injury, nonbeneficial therapy, and poor ICU survival were universally accepted as reasonable triggers. Severe illness alone was not considered an appropriate reason to trigger a WH/WD discussion, as potential illness reversibility was considered more important. In summary, there was general agreement supporting the use of several practical triggers; however, it was agreed that universally acceptable triggers would be difficult to identify, and the list developed at this round table meeting should serve as a guide only. The round table statements of general agreement identify common triggers and provide different indication grades (may, should usually, and should always) for the use of common triggers, guided by the degree of agreement achieved. All participants indicated that they would usually or always implement end-of-life discussions in response to advanced directives. It should, however, be recognized that, although advance directives are legally regulated in some countries (eg, United States, United Kindom, Australia, Netherlands, Germany, Spain, Singapore, and India), they are generally respected but not legally regulated in others (eg, Italy, Switzerland, Hong Kong, Japan, and South Korea); and, thus, levels of implementation may vary [47-50]. In the free-text responses, members from Middle Eastern and Asian regions expressed the need to be aware of local, religious, and legal constraints when considering WH/WD discussions. Nevertheless, many of the processes described above were generally accepted as reasonable by all participants; and a table with agreed statements that some may find useful is provided (Table 4). The report has several limitations. The major limitation of this study is the composition of the round table group. Although participants were invited based on regional diversity, known interest in ethics, and perceived ability to represent their regions, some parts of the world and many cultures were not represented. Most participants represented ICUs of large, teaching hospitals. It is therefore likely that the practice and views of some parts of the world and those in smaller, local, or regional units were not fully represented. Nevertheless, both similarities and variations in practice and opinion were identified. The final recommendations therefore acknowledge both outlying practice and opinion as well as emphasize agreed principles and practice as clearly as possible. In addition, participant demographic data were not analyzed. The round table discussion was also not systematic a priori but concentrated on what were considered major issues. Thus, not all possible aspects of decision-making triggers were discussed at length, examples being the influence of "inability to continue to pay" by individuals in countries

where intensive care is provided on a strictly pay for service model, or the principle of distributive justice and its use as an ethical principle to justify decisions at end of life. Although no systematic attempt was made to reach agreement on this last issue, consideration of the use of the ethical principle of distributive justice at the end of life raises several challenges. The moral principle of distributive justice implies that there is possible justification for prioritization or triage at the end of life. In ICU-related literature on end of life, although the resource cost of prolonged and “low-benefit” life support has been challenged as being inappropriately high, no practical advice has been suggested as to how prioritization could be applied in this setting, nor have observational studies reporting its use been published. In general, most physicians tend to agree with Heaney et al [51], that clinicians believe that the physician's first duty is to the patient whom he/ she is currently treating and that we should avoid giving the family the impression that we stop treatment to “free a bed for another patient.” Pronovost and Angus [52] make the valid point that, in the absence of suitable methods to calculate economical basis for resource allocation, such considerations will remain limited. Recently, however, as part of a system of “triage” or prioritization during infectious outbreaks, it has been suggested that patients not responding positively to ICU care and with resultant poor prognosis should have life support withdrawn by discharge from the ICU [53]. Under these extreme circumstances of resource stress, it appears that prioritization of resources to maximize overall resource use at end of life may be considered acceptable. It could be argued that, in some poorly resourced countries, such a level of resource stress exists continuously and that routine triage could be justified and may be practiced; however, no current literature exists documenting this practice in resource-limited countries. Importantly, it should be remembered that if systematically practiced, under such circumstances, although overall societal resource utilization is maximized, personal choice at end of life is limited by the implementation of prioritization [54]. Early goal-of-care discussions or use of advance directives, when personal choice of rejection of unwanted burdens of prolonged ICU care may be expected to result in earlier WH/WD, also results in conservation of scarce ICU resources [48]. In this case, however, it is an indirect benefit and not the primary goal. Therefore, it is acknowledged, even in highly resourced countries, that medical resource consumption at the end of life cannot be unlimited, [55], and the reduction of health care costs at the end of life by early palliative care consultation has been shown to be associated with cost savings [56,57]. However, this approach would ultimately be successful at reducing costs in the ICU setting, and how it could be implemented, is currently unclear [58,59]. In conclusion, although there was majority agreement for several statements when making decisions to proceed to WH/WD, there was some disagreement, particularly by members representing Asia and the Middle East. This was particularly evident with regard to nursing participation in decision making, concerns regarding the legal status of WH/WD, and the effect of this on initiating discussions. Although all participants represented ICUs that practiced WH/WD, it was noted that, in certain regions of the world that may have had no representation, cultural or religious norms may directly influence the process of WH/WD and may in some places prohibit it entirely. Nevertheless, where practiced, a number of generally agreed statements to guide health care professional end-of-life decision making are provided. Participants in the Durban World Congress Ethics Round Table:

Country

Name

Institution

1

Australia

Jeff Lipman

2

Belgium

3

Canada

4

China

Jean-Louis Vincent Niranjan Kissoon Bin Du

Royal Brisbane and Women's Hospital, Herston Erasme University Hospital, Brussels BC Children Hospital, Vancouver Peking Union Medical College Hospital, Beijing

G.M. Joynt et al. / Journal of Critical Care 30 (2015) 224–230 (continued) Country

Name

Institution

5

France

Hôpital Saint-Antoine, Paris

6 7

France Germany

8 9

Hong Kong Israel

Bertrand Guidet Elie Azoulay Christiane Hartog Gavin Joynt Charles Sprung

Hôpital Saint-Louis, Paris University Hospital Jena, Jena

Prince of Wales Hospital, Shatin Hadassah Hebrew University Medical Center, Jerusalem 10 Saudi Arabia Khalid Shukri Pan Arab Critical Care Medicine Society, Riyadh 11 South Africa Eric Hodgson Addington Hospital, Durban 12 South Africa Andrew Argent Memorial Children's Hospital, Cape Town 13 South Africa Fathima Paruk University of the Witwatersrand, Johannesburg 14 South Africa Rudo Mathivha Chris Hani–Baragwanath Hospital, Soweto 15 South Africa Charles University of the Witwatersrand, Feldman Johannesburg 16 South Korea Younsuck Koh Asan Medical Center, Seoul 17 The A.B.J. Vrije Univerditeit Mecical Centre, de Netherlands Groenveld Boelelaan 18 United States Chris Farmer Mayo Clinic, Rochester 19 United States Mitchell Levy Rhodes Island Hospital, Providence 20 United States Janice The Methodist Hospital, Houston Zimmerman 21 United States Edgar J. Orlando Regional Medical Center, Orlando Jimenez 22 United States J. Randall University of Washington, Seattle Curtis

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