End-of-Life Decision-Making in Intensive Care Ten Years after a Law on Advance Directives in Germany

• Main Authors: Jan A. Graw, Fanny Marsch, Claudia D. Spies, Roland C. E. Francis
• Format: Article
• Language: English
• Published: MDPI AG 2021-09-01
• Series: Medicina
• Subjects: end-of-life decision; advance directive; intensive care unit; shared decision-making
• Online Access: https://www.mdpi.com/1648-9144/57/9/930

<i>Background and Objectives</i>: Mortality on Intensive Care Units (ICUs) is high and death frequently occurs after decisions to limit life-sustaining therapies. An advance directive is a tool meant to preserve patient autonomy by guiding anticipated future treatment decisions once decision-making capacity is lost. Since September 2009, advance directives are legally binding for the caregiver team and the patients’ surrogate decision-maker in Germany. The change in frequencies of end-of-life decisions (EOLDs) and completed advance directives among deceased ICU patients ten years after the enactment of a law on advance directives in Germany is unknown. <i>Materials and Methods</i>: Retrospective analysis on all deceased patients of surgical ICUs of a German university medical center from 08/2008 to 09/2009 and from 01/2019 to 09/2019. Frequency of EOLDs and advance directives and the process of EOLDs were compared between patients admitted before and after the change in legislation. (No. of ethical approval EA2/308/20) <i>Results:</i> Significantly more EOLDs occurred in the 2019 cohort compared to the 2009 cohort (85.8% vs. 70.7% of deceased patients, <i>p</i> = 0.006). The number of patients possessing an advance directive to express a living or therapeutic will was higher in the 2019 cohort compared to the 2009 cohort (26.4% vs. 8.9%; difference: 17.5%, <i>p</i> < 0.001). Participation of the patients’ family in the EOLD process (74.7% vs. 60.9%; difference: 13.8%, <i>p</i> = 0.048) and the frequency of documentation of EOLD-relevant information (50.0% vs. 18.7%; difference: 31.3%, <i>p</i> < 0.001) increased from 2009 to 2019. <i>Discussion</i>: During a ten-year period from 2009 to 2019, the frequency of EOLDs and the completion rate of advance directives have increased considerably. In addition, EOLD-associated communication and documentation have further improved.