End-of-life practices in Hong Kong intensive care units: results from the Ethicus-2 study

Introduction: The need for end-of-life care is common in intensive care units (ICUs). Although guidelines exist, little is known about actual endof-life care practices in Hong Kong ICUs. The study aim was to provide a detailed description of these practices. Methods: This prospective, multicentre observational sub-analysis of the Ethicus-2 study explored end-of-life practices in eight participating Hong Kong ICUs. Consecutive adult ICU patients admitted during a 6-month period with lifesustaining treatment (LST) limitation or death were included. Follow-up continued until death or 2 months from the initial decision to limit LST. Results: Of 4922 screened patients, 548 (11.1%) had LST limitation (withholding or withdrawal) or died (failed cardiopulmonary resuscitation/brain death). Life-sustaining treatment limitation occurred in 455 (83.0%) patients: 353 (77.6%) had decisions to withhold LST and 102 (22.4%) had decisions to withdraw LST. Of those who died without LST limitation, 80 (86.0%) had failed cardiopulmonary resuscitation and 13 (14.0%) were declared brain dead. Discussions of LST limitation were initiated by ICU physicians in most (86.2%) cases. Shared decision-making between ICU physicians and families was the predominant model; only 6.0% of patients retained decision-making capacity. Primary medical reasons for LST limitation were unresponsiveness to maximal therapy (49.2%) and multiorgan failure (17.1%). The most important consideration for decision-making was the patient's best interest (81.5%). Conclusion: Life-sustaining treatment limitations are common in Hong Kong ICUs; shared decision making between physicians and families in the patient's best interest is the predominant model. Loss of decision-making capacity is common at the end of life. Patients should be encouraged to communicate end-of-life treatment preferences to family members/ surrogates, or through advance directives.