Nurses were never included in consensus development, but were informed about the decisions. Almost always (98%), the attending physician stated that he or she was sure that he or she had made the right decision. Only 6% of patients in whom CPR was Ruxolitinib INCB018424 withheld had a written account of the “do not resuscitate” (DNR) decision present in their charts. However, decisions to forego (withhold or withdraw) life-sustaining therapy (besides CPR) were documented in the medical record in 52% of the corresponding cases.The therapeutic interventions most frequently withheld/withdrawn were vasopressors/inotropes and dialysis. Other life-support modalities withheld/withdrawn are shown in Table Table8.8. The median time from ICU admission to the decision to withhold treatment was 8.5 days (range, 0 to 129 days).

The median time from withholding of therapy to death was 48 hours (range, 0.5 hours to 30 days). The median time from ICU admission to the decision to withdraw treatment was 14 days (range, 3 to 116 days). The median time from withdrawal of therapy to death was 32 hours (range, 1 hour to 4 days). The withholding or withdrawal decision was considered by physicians to have been timely in 79% of cases and inappropriately delayed in 21%.Table 8Life-support modalities withheld/withdrawnDiscussionThe present multicenter study demonstrates that limitation of life-sustaining treatment is a common phenomenon in Greek ICUs; more than half of deaths are preceded by a decision to forego some form of supportive therapy. Nevertheless, in the vast majority of cases (>80%), the only limitation of treatment that takes place is withholding of CPR.

Withholding of other life-support modalities besides CPR is not a routine practice, whereas withdrawal of treatment is quite infrequent. The observed rate of CPR use (40.5%) is consistent with data reported from southern countries (Greece, Israel, Italy, Portugal, Spain, and Turkey) in the European Ethicus study, and is much higher than the European mean (21%) [3]. In northern European countries, as well as in North America, the incidence of withholding and withdrawal of life-sustaining treatment reaches 90% of patients who die in the ICU [3,15].A remarkable observation of the current study is that withdrawal of mechanical ventilation happens only on rare occasions.

Although the same moral justification is required to withdraw one form of support or another [16], withdrawal of mechanical ventilation seems to be a taboo practice. Clearly, given that patients usually die soon after ventilator withdrawal, most Greek physicians see ventilator support as the ultimate tool in life support, which cannot be withdrawn without taking personal Dacomitinib responsibility for the death of a patient.International discrepancies in end-of-life practices have been considered to reflect cultural and religious differences [13,14,17].