gms | German Medical Science

Objective: End of Life decisions (ELD) have come into focus of the public interest since the latest amendment of the German patients' bill of rights (GerBOR), November 2011. A change in the understanding of self-decreed rights for the personal integrity and well-being in the general population led to a increased discussion in public and media with respect to patients' decrees to refuse a potential necessary treatment or limit supportive care in end stage disease. It is our purpose to analyze proceedings in ELD with special focus on the role of pre-existing patient decrees and the role of the putative living will.

Method: All cases of death on the neurosurgical ICU between January 2012 and May 2014 were analyzed retrospectively from the medical charts.

Results: 127 of 2835 patients died during this period (4.47%; 66 female, 61 male; mean age at death 66.06 y). Diagnosis leading to death were SAH (n=25), ICH (n=36), TBI (n=41), tumors (n=21) and others (n=2). Infaust prognosis or progressive decline of the patient's clinical situation limited further therapy in 40 cases, 9 patients died despite maximum treatment efforts. Brain death was diagnosed in 18 patients, leaving a total of 56 patients with need to decide for escalation of intensive care treatment or for limitation of therapy. Of these only 20 patients (15,75%, mean age at death 73,45y) had a patient decree or power of attorney. 4 patients were able to decide against further treatment because they were still in mental good condition. Thus, treatment decision had to be made in close agreement with family members or civil partners in the putative living will of 36 patients. In all cases it was possible to take ELD consensually, leading to gradual reduction of intensive care support or termination of ventilation or catecholamine therapy.

Conclusions: Improved pre-hospital care and initial treatment standard have shifted the ELD into the ICU in the majority of cases. This applies with special consideration of the demographic trends and the consequent aging of our patients. Even though, patient decrees become more common on the background of GerBOR there is still growing need for the treating physicians on the ICU to take ELD in close agreement with the relatives and /or civil partners. Currently, a survey is ongoing to estimate the overall prevalence of patient decrees in neurosurgical patients. Indisputable, the GerBOR has a major impact on the patients' care, especially on the ICU.