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Intensive Care Med (2006) 32:955957DOI 10.1007/s00134-006-0184-8 E D I T O R I A L

Jean-Michel Boles End of life in the intensive care unit:

from practice to law.

What do the lawmakers tell the caregivers?A new series in Intensive Care Medicine

Received: 31 March 2006Accepted: 31 March 2006Published online: 23 May 2006 Springer-Verlag 2006

J.-M. BolesHpital de la Cavale Blanche Centre Hospitalier Universitaire,Service de Ranimation mdicale et Urgences mdicales,Boulevard Tanguy Prigent, 29609 Brest cedex, France

J.-M. Boles (u)Facult de Mdecine et des Sciences de la Sant, Universit deBretagne Occidentale, Department of Human and Social Sciences,Research Group (ERCS) Ethique, professionnalisme et sant,Avenue Camille Desmoulins, 29238 Brest cedex 03, Francee-mail: jean-michel.boles@chu-brest.fr

Tel.: +33-2-98347181Fax: +33-2-98347965

Decisions to forgo life-sustaining treatment (DFLST) andend-of-life (EOL) care in intensive care units (ICUs) havebeen a major subject of interest among intensivists inthe past 15 years. Many studies have reported decisionprocedures and EOL practices in ICUs in many countries,e.g. the USA [1], France [2], Spain [3], Israel [4], GreatBritain [5] and more recently Turkey [6] and Lebanon [7].These studies have shown that 40% to more than 50% ofall deaths occurring in ICUs follow DFLSTs [1, 2, 5]. TheEthicus study performed in European ICUs showed signi-ficant differences in approaches to EOL decisions amongcountries and underlined the role of cultural characteristicsin doctors attitudes [8]. To sum up, Europes paternalistictradition, particularly in southern countries, is opposedto the American autonomistic attitude [9]. Middle Eastcountries have their own specificities, largely influencedby religion, which result in different attitudes, even thoughmany of their physicians were trained in Europe or inthe United States [10, 11]. North American professionalsocieties [12] and many European national professional

societies [13, 14, 15, 16] have adopted and published

recommendations about EOL care. These were presentedat the 5th International Consensus Conference in IntensiveCare Medicine [17, 18], organized by five intensive caresocieties, which was held in Brussels in April 2003. Theconsensus statement, written by an international jury andpublished in Intensive Care Medicine in 2004, delineatedgeneral rules for procedures to make DFLSTs and provideEOL patients with the best possible care [19]. Finally, tworecent books focused specifically on this subject [20, 21].

The ethics of death in the ICU has undergone majorchanges in the past 20 years, driven by powerful princi-ples: moving towards autonomous decisions, autonomyby surrogate, truth telling, clarifying confusing dis-

tinctions, overruling autonomy, withstanding medicalresistance [22]. Societys changing perception of death,changes in law and jurisprudence, and limits in allocationof resources have also driven this evolution [22]. Thequestions raised reflect the complexity of human situationscreated by illness or trauma and by the advances inmedical knowledge and technology. Many factors have tobe taken into account: the increasing desire of individualsfor autonomy, the influence of race, ethnicity, religion andsocioeconomic status on patients attitudes toward EOLcare [23], societys values and traditions, the particularitiesof each countrys legal and judicial system, and what hasbeen designated as legal liabilities anxieties of ICUdoctors [24]. Though doctors frequently express fearabout legal liabilities, the rate of litigation after deathresulting from DFLST has been estimated at 0.30.5% inthe USA [24], and the last two annual reports of the mainFrench medical insurance company contained no case oflitigation resulting from such a complaint.

EOL decisions and care have generated aggres-sive public debate, extensive media coverage, highlypublicized judicial rulings and forceful government in-volvement leading to new legislation in many countries.This trend started with the Karen Quinlan case in the USA

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in 1976 and was followed by other painful instances suchas the Nancy Cruzan case in 1990, leading to much newjurisprudence [22, 25] and to new US federal legislationas well as state legislation. In all these circumstancesimpressive media coverage fuelled public debate. Forexample, when the Terry Schiavo affair came to a climax

in early 2005, the American international magazine Timemade the case its cover story under the title The end oflife. Who decides? [26]. One must remember that eachcountry has its own judicial system. For example, underthe American judicial system, a plaintiff may resort tocourt in the case of severe disagreement with a decisionproposed by the medical team in order to initiate a judicialruling; the court is then requested to supply a decisionwith equitable relief [24, 25]. Several cases have cometo court in England and Australia, which have comparablesystems, the court decision differing according to thecircumstances of each case [27]. Under the French judicialsystem, however, courts always rule about facts that have

happened, as a plaintiff may initiate a lawsuit only after anevent has actually occurred. Finally, the European Courtof Human Rights, Europes highest court of justice, haspassed important trend judgments in this matter, such asPretty vs. the United Kingdom in 2002, in which the courtconcluded that no right to die could be equivalent to that oflife, nor could a right to die be derived from the European

Convention of Human Rights [28]. Legislation from eachcountry is interesting to analyze, as laws represent a soci-etys answer to a problem at a particular moment and havea major impact on making medical practices evolve to bet-ter answer peoples expectations. For instance, Belgiumand the Netherlands have a law authorizing euthana-

sia [29], whereas France passed a law on EOL in 2005,after a major public scandal, deliberately excluding eu-thanasia or medically assisted suicide from its scope [30].

Intensive Care Medicine has decided to publish a newsection headed End of life: from practice to law. The firstthree articles will deal with the Israeli, Indian and Dutchlegislations. The goal of this section is to inform readers ofthe way each country has coped with this difficult question,to compare the diversity of solutions brought to a widearray of questions: How do national cultural particularitiestranslate into law? To what extent is patient autonomy ac-cepted and promoted? Are advanced directives legally ac-cepted? Can anyone designate a surrogate and what is his

real power? Does the law protect the patients rights andauthorize doctors to make DFLSTs? Are DFLSTs clearlydistinguished from euthanasia? Is the latter allowed or tol-erated?

We sincerely hope this new section will stimulate thedebate about EOL in the ICU among intensivists fromcountries all over the world.

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