Association between education in EOL care and variability in EOL practice: a survey of ICU physicians

Intensive Care Med. 2012 Mar;38(3):404-12. doi: 10.1007/s00134-011-2400-4. Epub 2012 Jan 6.


Purpose: This study investigated the association between physician education in EOL and variability in EOL practice, as well as the differences between beliefs and practices regarding EOL in the ICU.

Methods: Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, as well physicians' personal, professional and EOL educational characteristics.

Results: The response rate was 89%, with 105 questionnaires analyzed. Mean age was 38 ± 8 years, with a mean of 14 ± 7 years since graduation. Physicians who did not apply do-not-resuscitate (DNR) orders were less likely to have attended EOL classes than those who applied written DNR orders [0/7 vs. 31/47, OR = 0.549 (0.356-0.848), P = 0.001]. Physicians who involved nurses in the decision-making process were more likely to be ICU specialists [17/22 vs. 46/83, OR = 4.1959 (1.271-13.845), P = 0.013] than physicians who made such decisions among themselves or referred to ethical or judicial committees. Physicians who would apply "full code" had less often read about EOL [3/22 vs. 11/20, OR = 0.0939 (0.012-0.710), P = 0.012] and had less interest in discussing EOL [17/22 vs. 20/20, OR = 0.210 (0.122-0.361), P < 0.001], than physicians who would withdraw life-sustaining therapies. Forty-four percent of respondents would not do what they believed was best for their patient, with 98% of them believing a less aggressive attitude preferable. Legal concerns were the leading cause for this dichotomy.

Conclusions: Physician education about EOL is associated with variability in EOL decisions in the ICU. Moreover, actual practice may differ from what physicians believe is best for the patient.

MeSH terms

  • Adult
  • Analysis of Variance
  • Attitude of Health Personnel*
  • Brazil
  • Critical Care / ethics
  • Critical Care / methods
  • Critical Care / standards*
  • Decision Making
  • Education, Medical / standards
  • Education, Medical / statistics & numerical data
  • Ethics Committees, Clinical
  • Female
  • Health Care Surveys
  • Humans
  • Intensive Care Units / standards*
  • Intensive Care Units / statistics & numerical data
  • Male
  • Physician-Nurse Relations
  • Practice Patterns, Physicians'
  • Resuscitation Orders / ethics
  • Terminal Care / ethics
  • Terminal Care / methods
  • Terminal Care / standards*
  • Workforce