Attitudes towards ethical problems in critical care medicine: the Chinese perspective

Abstract

Introduction

Critical care doctors are frequently faced with clinical problems that have important ethical and moral dimensions. While Western attitudes and practice are well documented, little is known of the attitudes or practice of Chinese critical care doctors.

Methods

An anonymous, written, structured questionnaire survey was translated from previously reported ethical surveys used in Europe and Hong Kong. A snowball method was used to identify 534 potential participants from 21 regions in China.

Results

A total of 315 (59%) valid responses were analysed. Most respondents (66%) reported that admission to an intensive care unit (ICU) was commonly limited by bed availability, but most (63%) would admit patients with a poor prognosis to ICU. Only 19% of respondents gave complete information to patients and family, with most providing individually adjusted information, based on prognosis and the recipient’s educational level. Only 28% disclosed all details of an iatrogenic incident, despite 62% stating that they should. The use of do not resuscitate orders or limitation of life-sustaining therapy in terminally ill patients reported as uncommon and according to comparable reports, both are more common practice in Hong Kong or Europe. In contrast to European practices, doctors were more acquiescent to families in decision-making at the end of life.

Conclusions

A number of differences in ethical attitudes and related behaviour between Chinese, Hong Kong and European ICU doctors were documented. A likely explanation is differing cultural background, and doctors should be aware of likely expectations when treating patients from a different culture.

Appendix

The Chinese Critical Care Ethics Group consists of:

Coordinators Liang FJ (Beijing Geriatric Hospital); Mao RZ (The First Affiliated Hospital of Henan College of Traditional Chinese Medicine); Wang XW (Qinghai Red Cross hospital); Bu L (Liaoning Jinqiu Hospital); Xu YH (Cancer Hospital, Chinese Academy of Medical Sciences, Beijing); Cao W (LanZhou University Second Hospital); Liu FY (Cangzhou Central Hospital); Zhu FX (The Affiliated Jingzhou Hospital of Tongji Medical College of Huazhong University of Science and Technology); Fu HJ (The First Affiliated Hospital of Soochow University); Ning B (Beijing General Hospital of Air Force); Xie YC (Henan Yuzhou People’s Hospital); Zhou Y (Tongde Hospital of Zhejiang Province); Qi JY (Guangdong Dongguan Shilong Boai Hospital); Akbar (The First affiliated Hospital of Xinjiang Medical University); Zhang R (Yi Chang Centre Hospital).

Survey questionnaire

• 1. How often is intensive care unit (ICU) admission affected by the limited availability of beds? (almost always, often, sometimes, seldom, almost never)

• 2. Do you (should you *) usually admit a patient to the ICU if:

  • a. The chance of survival was less than a few weeks (y/n)

  • b. The chance of survival was less than a few months (y/n)

  • c. The patient may survive a few years, but with a poor quality of life (y/n)

  • d. The patient believes he or she will survive for a few years, but with a poor quality of life (y/n)

• 3. Do you have an admission policy in your ICU?

  • a. Yes, there is a written policy and guideline

  • b. Yes, there is an overall policy but it is understood and not written

  • c. No, it depends on the doctors individual decision

  • d. No, admission is on “first come first serve” basis

• 4. When providing medical information (diagnosis, treatment, prognosis) to the patient and or relatives, do you (should you) usually:

  • a. Explain everything to the patient and relatives with no exception

  • b. Explain on the basis of the type of disease and severity of prognosis

  • c. Explain depending on the level of patient’s and relatives’ education and expectation

  • d. b + c combined

• 5. When an iatrogenic incident (avoidable mistake) occurs, do you (should you) tell the patient/relatives:

  • a. Exactly what happened, including that the complications were caused by the medical error

  • b. That the complications occurred, but minimize the iatrogenic aspects to try to avoid the responsibility

• 6. A. If a competent patient refuses a surgical intervention, which you think is necessary and can be “life-saving”, you will:

  • a. Try your best to explain to the patient, but will accept the patient’s decision if he or she insists

  • b. Treat the patient correctly, contrary to his wishes

  • c. Advise the patient you will no longer treat him/her

•  

  B. If a competent patient refuses a surgical intervention, which you think is necessary but is not “life-saving”, you will:

  • a. Try your best to explain to the patient, but will accept the patient’s decision if he or she insists

  • b. Treat the patient correctly, contrary to his wishes

  • c. Advise the patient you will no longer treat him/her

• 7. In the event of a cardiac arrest, do you (should you) apply “do not resuscitate” (DNR) orders?

  • a. Yes, if there is a written DNR order

  • b. Yes, if there is a verbal DNR order

  • c. No, the DNR order limits the level of care for patient

  • d. No, the doctor should try to resuscitate every patient in ICU

• 8. If “do not resuscitate” orders are used, do you (should you) usually discuss it with the patient and relatives?

  • a. Yes

  • b. No, not necessary

• 9. For patients with no real chance of recovering a meaningful life, how often have you: (almost always, often, sometimes, seldom, almost never)

  • a. Withheld further active treatment, but continued current treatment (such as not starting vasopressor and haemodialysis)

  • b. Withdrawn sophisticated therapy (such as stopping vasopressor and haemodialysis)

  • c. Deliberately given large doses of drugs intentionally (e.g. barbiturate or morphine) until death ensues

• 10. Please choose the most appropriate statements about your attitude towards hopeless patients—patients who have no hope of being cured (please choose after reading through all the statements)

  • A. Comparison between limitation of therapy (stopping further active treatment or withdraw current therapy) and euthanasia (directly administer or prescribe a medication to provoke death)

    • a. I think limitation of therapy is a passive form of euthanasia, because both lead to death

    • b. Limitation of therapy is neither an active nor passive form of euthanasia. Euthanasia has the intention to kill the patient, while limitation of therapy does not have the intention of killing the patient

  • B. Regarding limitation of therapy and euthanasia

    • a. Both are acceptable

    • b. Both are NOT acceptable

    • c. Euthanasia is NOT acceptable, but limitation of therapy is acceptable

  • C. During the practice of limitation of therapy, withholding (not increasing) and withdrawal of life support treatment are:

    • a. Ethically the same, because both lead to death

    • b. Ethically are not the same, because withholding means the maintenance of (not increasing) the level of current life support, while withdrawal of therapy actively reduces the level of current life support treatment

• 11. How many deaths occur due to limitation of therapy in your ICU?

  • a. 0–20%

  • b. 21–40%

  • c. 41–60%

  • d. 61–80%

  • e. 81–100%

• 12. In your ICU who does (should) usually make the decision of limitation of therapy (not increase or withdraw life support treatment)? (you can choose more than one answer)

  • a. ICU doctors

  • b. ICU nurses

  • c. Parent specialty doctors

  • d. Patient or family representatives

• 13. In your experience, the estimated percentage of relatives who finally accept limitation of therapy is

  • a. 0–20%

  • b. 21–40%

  • c. 41–60%

  • d. 61–80%

  • e. 81–100%

• 14. Do you feel comfortable while talking about limitation of therapy to the patient’s relatives? (almost always, often, sometimes, seldom, almost never)

• 15. In your ICU practice, how often does a patient or surrogate request inappropriate therapy (e.g. continue active life support for a comatose dying patient)? (almost always, often, sometimes, seldom, almost never)

• 16. Is there a policy or mechanism to overrule the inappropriate request from patient’s relatives in your ICU? (y/n)

• 17. Can ethics consultant or committee help in the decision of limitation of therapy?

  • a. Yes, they may provide some help

  • b. No, they will provide no help

• 18. Should medical training programmes teach more ethics? (y/n)

• 19. A 50-year-old male patient suffering from chronic obstructive pulmonary disease (COPD) for many years has been admitted repeatedly due to respiratory failure, and has required repeated prolonged ventilatory support. This time he is suffering from respiratory failure again, together with prolonged cardiac arrest. After 72 h, he is still deeply comatose and requires ventilatory support.

  Please choose from the following answers under the following conditions:

  • A. Patient has no relatives

  • B. Patient’s relatives insist on cessation of further treatment and withdrawal of therapy

  • C. Patient’s relatives insist on the most active treatment

    • a. Continue the full active support treatment including cardio-pulmonary resuscitation (CPR) if patient has cardiac arrest again

    • b. Continue the most active support treatment but not include CPR

    • c. Continue current treatment but not give further complicated treatment (e.g. haemodialysis, surgical intervention)

    • d. Continue current treatment but not give further additional treatment (e.g. antibiotics for treating sepsis)

    • e. Stop mechanical ventilation (allow patient to die)

    • f. Stop all treatment (intravenous infusion, NG feeding) except mechanical ventilation

    • g. Obtain ethics consultation

• 20. Are you aware of any (national or local) legal policies or specific laws that are relevant to the following end-of-life issues in ICU? (y/n)

  • a. Euthanasia

  • b. Do not resuscitate orders

  • c. Limitation of therapy (withholding or withdrawing)

  • d. Brain death

  If the answer to this question is yes, what does the law state, and do you know where a reference to it can be found? (free text)

• 21. A. Do you feel that you are exposed to personal legal risk if you would practice any of the following? (y/n)

  B. Do you believe that national or local legislation should determine the practice of the following? (y/n)

  • a. Euthanasia

  • b. Do not resuscitate orders

  • c. Limitation of therapy (withholding or withdrawing)

  • d. Brain death

*Question repeated with alternative “should you” replacing “do you”; see also questions 4, 5, 7, 8 and 12.