End of life in the intensive care unit: knowledge and practice of clinicians from Karachi, Pakistan

Background: With improvements in the care of critically ill, physicians are faced with obligations to provide quality end-of-life care. Barriers to this include inadequate understanding of the dying patient and withdrawal or limitation of care. The objectives of this study were to document the comprehensions of physicians and nurses regarding the recognition and practice of end-of-life care for critically ill patients placed on life support in the intensive care unit. Methods: This was a cross-sectional study carried out at three hospitals in Karachi. Chi-squared analysis and one-way ANOVA were used to compare differences in response between the groups. Results: One hundred and thirty-seven physicians and critical care nurses completed the survey. 'Brain death' was defined as an 'irreversible cessation of brainstem function' by 85% respondents, with 50% relying on specialty consultation. Withdrawal of life support is practised by 83.2%; physicians are more likely (Chi square test P-value < 0.001) to withdraw mechanical ventilation, compared with nurses who would withdraw vasopressors (P-value 0.006). In a do not resuscitate patient, 72.3% use vasopressors, 83% initiate haemodialysis and 17.5% use non-invasive ventilation; 72.6% consult Hospital Ethics Committees; 16% respondents never withdraw life support; 28.3% considered it their responsibility to 'sustain life at all costs' and only 8% gave religious beliefs as a reason. Conclusions: There are confusions in the definition of brain death, end-of-life recognition and indications and processes of withdrawal of life support. There are discrepancies between physicians' and nurses' perceptions and attitudes. Clearly, teaching programmes will need to incorporate cultural and religious differences in their ethics curricula.