End of life practices in India
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KeywordsAdvance Directive Underlie Disease Process Tertiary Care Teaching Hospital Paternalistic Approach American Ethos
'End of life' (EOL) decisions in ICUs are influenced by numerous factors such as patient's disease severity and reversibility, religious and cultural traits, education and awareness of the patient's family and legal provisions. The majority of published studies on EOL reflect either a European or an American ethos; that is, either the physician's paternalistic approach about the patient or the patient's autonomy and self-determination about this sensitive process. Studies that reflect the influence and pivotal role of a closely knit Indian family in EOL decision-making are scant. We retrospectively analysed the EOL decisions taken by the family in our ICU.
The setting was a 50-bed multidisciplinary ICU of a 400-bed tertiary care teaching hospital in Pune in India. Case papers of all ICU admissions during 1 year (1 January–31 December 2006) where the EOL decision was documented were reviewed. Data collected included demographics, underlying disease process, duration of aggressive treatment until EOL consent, duration between EOL decision and death, consenting person's relation with the patient, organ failure and level of life-sustaining supports at decision.
During the study period 524 patients died in our ICU, of which EOL decision and consent was explicitly documented in 95 cases, which constitute the study population. The average age of the patient was 63 years (range 17–91), the average duration of active treatment until EOL consent was 83.35 hours (range 1–960), and the average duration between consent and death was 29.03 hours (range 1–168). A total of 92.7% consents were signed by close relatives (son/daughter, brother/sister, spouse, father/mother) and 7.3% were by other relatives (cousins, son in law/daughter in law). No EOL decision was signed by the patient or his/her legal representative as well as the physician. No EOL decision was taken as per a patient's self-documented own 'Death Will' or 'Advanced Directive'.
Withholding nonbeneficial life-sustaining therapies as an EOL process was practised in 18.12% of the total ICU deaths. All 95 (100%) EOL decisions as well as directive requests and consents were signed by patients' relatives, reflecting the importance of close family ties in Indian EOL practices.
This article is published under license to BioMed Central Ltd.