Ganz F D, Benbenishty J, Hersch M, Fischer A, Gurman G, Sprung C L
Hadassah-Hebrew University School of Nursing, Kiryat Hadassah, PO Box 12000, Jerusalem, Israel.
J Med Ethics. 2006 Apr;32(4):196-9. doi: 10.1136/jme.2005.012542.
Decisions of patients, families, and health care providers about medical care at the end of life depend on many factors, including the societal culture. A pan-European study was conducted to determine the frequency and types of end of life practices in European intensive care units (ICUs), including those in Israel. Several results of the Israeli subsample were different to those of the overall sample.
The objective of this article was to explore these differences and provide a possible explanation based on the impact of culture on end of life decision making.
All adult patients admitted consecutively to three Israeli ICUs (n = 2778) who died or underwent any limitation of life saving interventions between 1 January 1999 and 30 June 2000 were studied prospectively (n = 363). These patients were compared with a similar sample taken from the larger study (ethics in European intensive care units: ETHICUS) carried out in 37 European ICUs. Patients were followed until discharge, death, or 2 months from the decision to limit therapy. End of life decisions were prospectively organised into one of five mutually exclusive categories: cardiopulmonary resuscitation (CPR), brain death, withholding treatment, withdrawing treatment, and active shortening of the dying process (SDP). The data also included patient characteristics (gender, age, ICU admission diagnosis, chronic disorders, date of hospital admission, date and time of decision to limit therapy, date of hospital discharge, date and time of death in hospital), specific therapies limited, and the method of SDP.
The majority of patients (n = 252, 69%) had treatment withheld, none underwent SDP, 62 received CPR (17%), 31 had brain death (9%), and 18 underwent withdrawal of treatment (5%). The primary reason given for limiting treatment was that the patient was unresponsive to therapy (n = 187). End of life discussions were held with 132 families (36%), the vast majority of which revolved around withholding treatment (91% of the discussions) and the remainder concerned withdrawing treatment (n = 11, 9%). There was a statistically significant association (chi2 = 830.93, df = 12, p < 0.0001) between the type of end of life decision and region-that is, the northern region of Europe, the central region, the southern region, and Israel.
Regional culture plays an important part in end of life decision making. Differences relating to end of life decision making exist between regions and these differences can often be attributed to cultural factors. Such cultures not only affect patients and their families but also the health care workers who make and carry out such decisions.
患者、家属及医护人员关于临终医疗的决策取决于诸多因素，包括社会文化。开展了一项泛欧洲研究，以确定欧洲重症监护病房（ICU）（包括以色列的ICU）临终医疗行为的频率及类型。以色列子样本的若干结果与总体样本不同。
本文旨在探究这些差异，并基于文化对临终决策的影响给出可能的解释。
对1999年1月1日至2000年6月30日期间连续入住以色列三家ICU且死亡或接受任何生命支持干预限制的所有成年患者（n = 2778）进行前瞻性研究（n = 363）。将这些患者与从在37家欧洲ICU开展的规模更大的研究（欧洲重症监护病房伦理：ETHICUS）中选取的类似样本进行比较。对患者进行随访，直至出院、死亡或自决定限制治疗起2个月。临终决策被前瞻性地分为五个相互排斥的类别之一：心肺复苏（CPR）、脑死亡、 withhold治疗、 withdraw治疗以及积极缩短死亡过程（SDP）。数据还包括患者特征（性别、年龄、ICU入院诊断、慢性疾病、入院日期、决定限制治疗的日期和时间、出院日期、在医院死亡的日期和时间）、受限的具体治疗以及SDP的方式。
大多数患者（n = 252，69%）接受了 withhold治疗，无人接受SDP，62人接受了CPR（17%），31人被判定脑死亡（9%），18人接受了withdraw治疗（5%）。限制治疗的主要原因是患者对治疗无反应（n = 187）。与132个家庭（36%）进行了临终讨论，其中绝大多数围绕withhold治疗（讨论的91%），其余涉及withdraw治疗（n = 11，9%）。临终决策类型与地区（即欧洲北部地区、中部地区、南部地区和以色列）之间存在统计学显著关联（卡方 = 830.93，自由度 = 12，p < 0.0001）。
地区文化在临终决策中起重要作用。不同地区在临终决策方面存在差异，且这些差异通常可归因于文化因素。此类文化不仅影响患者及其家属，还影响做出并执行此类决策的医护人员。 （注：原文中withhold和withdraw在医学语境下可能有特定含义，这里直接保留英文未准确翻译其医学意义，仅按字面翻译，可能影响对内容的准确理解。）
