Introduction

The aim of palliative care is to optimize the quality of life by anticipating, preventing, and treating suffering. The aim of intensive care is to provide organ and vital function support with the attempt to reduce morbidity and mortality during critical illness [1]. Physicians working in intensive care unit (ICU) commonly deal with clinical situations where a further intensity of care may result in futile therapies [2,3,4,5]. According to recent data, about one third of patients were admitted to ICU in the last month of their life, with an increasing trend during the last decade [6]. Both critically ill patients and their relatives experience a burden of unpleasant symptoms and negative effects of the ICU stay [7,8,9,10,11]. Many problems occurring in ICU typically regard palliative care practice. During the last decade, there has been a growing interest in incorporating palliative care principles in critical care settings [12,13,14,15,16,17,18,19]. This approach could result in an improvement of patient and family-oriented outcomes, but also in a more favorable ICU staff satisfaction [20, 21]. Many factors may influence this approach in ICU, for example the presence of a palliative care team, protocols for withholding and withdrawal of organ support therapies, and a good capability to communicate with relatives [16]. Different scientific societies and organizations have endorsed guidelines and promoted recommendations to implement palliative care in ICU [17, 22,23,24,25,26,27]. Recently, the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM) released a report on this topic, summarizing the available data and policies among countries [28]. Of interest, legal, ethical, cultural, religious, and organizational issues in ICU are different among countries [4, 5, 27, 29,30,31]. For this reason, WFSICCM has encouraged the debate on this topic within each country. The aim of this survey was to assess the attitudes of Italian anesthesiologists towards end-of-life issues, including the knowledge and practice in palliative care, and withholding and withdrawal of life-sustaining therapies in ICU.

Methods

Participants

Participants were recruited by a web-based survey endorsed by SIAARTI. (Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva). SIAARTI provided the online platform and database (MagNews – Diennea) to create a web-link with questions (see below). Answers to these questions were anonymously entered. An invitation with a brief description of the aim of the project was sent to all registered email addresses of SIAARTI members. A reminder was sent after 3 weeks from the first email. Invitation to join the survey was also emailed to all members of the national trade union AAROI EMAC (Associazione Anestesisti Rianimatori Ospedalieri Italiani Emergenza Area Critica). Many anesthesiologists in Italy belong to both societies.

Questionnaire

The questionnaire items were selected by consensus among the authors. The survey consisted of 27 closed-ended questions (16 multiple choice questions and 11 boolean questions) and 2 open-ended questions, globally divided in 2 sections: (1) information about the responder, his/her clinical practice, and institution and (2) information about the implementation of palliative care principles and practice in his/her ICU, including information about withholding and withdrawal of life-sustaining therapies. In 3 questions, more than one answer was allowed. The list of questions was reported in two web pages and in Italian (see Tables 1 and 2).

Table 1 List of questions, possible choices, and answers percentage-related responders characteristics and their institution (percentages were rounded)
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Table 2 List of questions, possible choices, and answers related to palliative care practice in ICU, including withdrawn and withholding. Percentages were rounded. Questions number 11 and 16 were open-ended question and are not reported in this table
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Statistical analysis

We reported the percentages of responders providing a given answer among the total sample. For multiple choice questions, we calculated and reported the percentages of each answer among total respondents. We compared the percentages of a given answer among different categories or subgroups by using the chi-square test. We considered as significant a two-tailed p value < 0.05. Prism 7 software (GraphPad software) for Windows was used for statistical analysis.

Results

Eight hundred and five persons responded to the full list of questions, whereas 998 responded only to those reported in the first web page, which included questions related to characteristics of respondents. We reported the data regarding the participants who completed the full survey.

Characteristics of responders

The answers to all close-ended questions are described in Tables 1 and 2. The highest amount of responders was in the age range of 36–45 years (34%), while a lower percentage of responders was ≤ 35 years old (18%). The responses were well balanced in terms of working hours spent in ICU. Concerning geographic distribution, more responders were working in Northern Italy (47%), whereas Central and Southern Italy were equally represented (25–28%). Most responders had more than 10 years of clinical practice (11–20 years, 29%; ≥ 21 years, 31%). Most responders reported to work in a public non-university hospital (64%) and in a general ICU (82%).

Religious belief

Most responders (41%) were believers (Catholic Religion) while about 25% of respondents reported to be “not believer” (Table 1).

Training in palliative care and existing teams

The vast majority of respondents (84%) did not receive a specific training in palliative/supportive care (Table 2). The age distribution of those who had a training is reported in Table 3. Age distribution was not homogeneous among ranges (p < 0.0001; chi-square 20.41). About 70% of respondents reported that there was no palliative/supportive care team in hospital (Table 1). The proportion of anesthesiologists who responded that there was a palliative/supportive care team in their hospital varied among regions (p = 0.0002; chi-square: 16.67) (Table 4).

Table 3 Response to question 23 according to responders’ age range
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Table 4 Response to question 10 according to geographic location of responders’ ICU
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From 213 answers to open-ended question 11 (not reported in Table 1: In your hospital, what is palliative/supportive care team comprised of?), the most common figures were anesthesiologists, nurses, oncologists, and psychologists.

Withdrawing/withholding

About two-thirds of responders (69%) reported that they usually adopt palliative care treatments in ICU patients when intensive treatments are considered futile (Table 1). However, 91% of respondents did not have protocols for withdrawing or withholding of life-sustaining therapies in their ICU. Consensus among the whole caring team was the most common way to take decisions about withdrawing/withholding of life-sustaining treatments (58%), followed by decision by the responsible of ICU (26%). Only 2% of responders reported to ask for external consultation with other specialists to take these decisions. Specialists who were most frequently involved in this decision were surgeons and palliative care specialists (open-ended question 16).

More than 70% of responders reported that, in their ICU, there was no collaboration with palliative/supportive care experts to interrupt or modify supporting treatments when considered futile (Table 1). Vasopressor or inotropic support (84%), extracorporeal therapies such as ECMO or renal replacement therapy (71%), and blood component transfusion (66%) were the most commonly modified/interrupted treatments. Moreover, a relevant number of responders declared to modulate oxygen supplementation (44%), nutrition (22%), and mechanical ventilation (19%). Invasive monitoring devices were frequently removed (60%); whereas, 37% of responders did not remove any commonly used devices in ICU patients (e.g., endotracheal tubes, central venous catheters). About half of responders (53%) reported that relatives’ access policy changed when a decision to modify patient’s treatment for futility was taken. Moreover, about 70% of respondents did not have protocols for sedation/analgesia in these situations. Opioids (48%) and benzodiazepines (30%) were the most commonly drugs used for this purpose. Regarding the symptoms usually recorded in palliative care, pain (67%) and dyspnea (50%) were the most commonly ones registered in ICU. Indeed, 20% of responders reported that none of these symptoms were systematically recorded. Most responders (82%) usually discuss with relatives about the short-term prognosis and clinical perspectives, including the possibility of withdrawing life-sustaining treatments. However, patient’s discharge from ICU was not allowed in more than 50% ICUs. Only 6% of respondents reported that patients with interrupted/modified therapies were allowed to come back home from ICU. Sixty percent of responders reported that they usually ask relatives about patients’ EOL dispositions. When physicians received this information, more than 90% of them respected these dispositions. Almost 60% of responders reported “do-not-resuscitate” orders were not given. In this case, more than 90% of respondents reported to respect it.

Discussion

This survey among Italian anesthesiologists provided interesting information regarding their attitudes towards different aspects of end-of-life issues in ICU.

Training in palliative care and existing teams

The most relevant findings of this survey were the lack of experience in palliative care of anesthesiologists who responded and the poor collaboration with a palliative care team.

Integrative, consultative, or mixed models are suggested to introduce palliative care in ICU teams. It seems that the “integrative model” is predominant, as external consultation or collaboration with palliative/supportive care experts are rarely performed. This model seeks to embed palliative care principles and interventions into daily practice by the ICU team for all critically ill patients and families [16]. To reach this goal, education in palliative/supportive care for the whole ICU team is required. According to present data, consultative or mixed models are difficult to realize, as most physicians reported do not have a palliative/supportive care team in their hospital.

Systematic symptoms’ recording is pivotal in palliative care. In fact, symptom assessment is the preliminary step to prescribe an appropriate therapy to alleviate patients’ suffering. Although symptom assessment is difficult in critically ill patients, validated scales and methods have been reported for pain, thirst, dyspnea, anxiety, and other symptoms [7, 32,33,34]. Regrettably, systematic symptom assessment is not frequent among respondents. This may be due to logistic and organizational issues but also to a lack of specific knowledge, despite educational resources, clinical tools, and guidelines have been extensively published and are easily accessible [16, 20, 32]. Of interest, the systematic registration of pain in the clinical chart has been recommended by an Italian law (legge 15 marzo 2010, no. 38) which underlined patients’ right to receive palliative care and pain therapy. This finding underlines that application of this law has been unsuccessful. Finally, implementation of palliative care seems to be not uniformly distributed, as more responders from Northern Italy reported to have a palliative/supportive care team in their hospital in comparison to other geographical macroareas [35].

Withdrawing/withholding

The most striking finding was that most respondents did not have protocols for withdrawing or withholding life-sustaining therapies and/or for analgesia/sedation in their ICU, even though strongly recommended [27]. Moreover, the vast majority of responders did not have established triggers and protocols to select patients for modifications/interruption of support in ICU. Hemodynamic support, extracorporeal therapies, and invasive monitoring devices were the most frequent modified or interrupted measures, while mechanical ventilation, nutrition, fluid therapy, and noninvasive monitoring were continued in most cases. Several factors may influence this practice, such as patients’ characteristics, physician’s beliefs and opinions, and local policies [27]. The low rate of mechanical ventilation withholding/withdrawal may be due to the perception of a “too strict” link with patient’s death. Moreover, legal aspects might strongly influence the decision of “not deciding”. Indeed, most guidelines suggest discontinuation of mechanical ventilation to avoid further distress or suffering to patients and to provide comfort in these circumstances [27]. Noninvasive monitoring may be noising due to alarms and discomfort. Its removal should be considered, as its role is questionable in these circumstances [27]. When a decision to withdrawn an intensive treatment is made, a team consensus is prevalently reached, although in a minority of cases, the head of ICU takes the responsibility for that. This aspect has obvious implication from an ethical and psychological point of view.

Half of responders reported that relatives’ access policy changes when there is a decision to modify patient’s treatment for futility. This aspect raises another challenging aspect in the ICU organization. Several practical procedures should be considered to ensure a better experience for patients and families, good death, and patient’s dignity before withholding or withdrawal of life support measures in ICU [1, 27, 30, 36]. For example, liberalizing visiting restrictions, removing unnecessary equipment and monitoring, discontinuation of mechanical ventilation, and ensuring quiet environment, may be beneficial to dying patients and their families.

Half of responders reported that discharge from ICU is not taken into account in these situations. Only a minority of patients was discharged home, which should be the desired option of relatives and, probably, patients. Discharge to other hospital settings (ward, hospice) may be an option due to shortage of ICU beds and economic reasons. However, it may be possible that physicians consider the discharge to a lower level of care as the best option for a dying patient to avoid restrictions and discomfort related to ICU. On the other hand, nowadays ICU should be considered a good place to die [1]. Families are not simple visitors in ICU and they can actively, emotionally, and spiritually be involved in every aspect of ICU staying [37]. Communication with relatives about clinical conditions, prognosis, and potential futility of treatment is a complex issue, often handled inadequately [37]. Moreover, relatives are often the depositary of patients’ wishes about intensive care treatments and EOL issues. Although our survey was not able to measure the quality of communication with relatives, the opinion of most responders is that, in their ICU, there is an open dialog on patient’s prognosis and possibilities to withhold or withdraw treatments. However, only two-thirds of responders reported that relatives are asked for patients’ EOL dispositions. When required these dispositions are usually respected. An eventual “do-not-resuscitate order” either from relatives or patients is not taken into account by 60% of responders. Even though considered by national SIAARTI guidelines for EOL in ICU [30], legal aspects may be the principal reason for this practice, as the “do-not-resuscitate” is not laid down by law [38].

Limitations

This survey has some limitations. First, it was not possible to calculate a precise response rate. Although the number of contacts who received the link via email is known (about 3500), there was no access restriction to the webpage. The survey has been widely discussed among colleagues at two national symposiums (70° SIAARTI national congress 2016 and 15° ACD SIAARTI national congress) and on the web through professional social networks (LinkedIn®, Researchgate®). The efforts for a widespread diffusion of the survey to increase the number of responses were justified by (1) the usual not high number of responses to endorsed surveys, (2) the potential limited interest for this topic by anesthesiologists not actively working in ICU and (3) the fact that some members of the involved societies do not regularly check the email account. On the other hand, it is likely that anesthesiologists working in ICU would be more interested in this survey. Of interest, more than 800 respondents working in ICU should represent a sufficient sample to draw some indications about the attitudes of Italian anesthesiologists towards end-of-life issues. Second, there was little space for more detailed and descriptive answers due to the low number of open-ended questions. We chose this design with the aim of balancing useful information and time to complete the survey. The short time needed to answer the full list of questions may have been a favorable factor for the relatively high number of final responses. Furthermore, the high number of close-ended questions was aimed to get clear, straight answers to important issues. It may be argued that several colleagues from the same institution may have completed the survey leading to redundant results. However, we believe that individual-based invitation is worthwhile, as even anesthesiologists from the same institution may have different opinions due to different subjective points of view and sensitivity to these issues. Thus, present data should be interpreted with caution since the generalizability to the whole Italian population of anesthesiologists is not accurate.

Conclusion

To the best of our knowledge, this was the first nation-wide survey specifically addressing the issues of palliative care practice, including withholding and withdrawal of life-sustaining therapies in ICU among Italian anesthesiologists. National surveys and investigations addressed the practice of withholding and withdrawal and/or EOL in ICU, whereas reports on palliative care practice are rare [39,40,41,42,43,44,45].

This survey suggests that there is a need for improving knowledge about palliative care practice among anesthesiologists working Italian ICUs. Moreover, the management of EOL seems to be not homogenous across respondents’ ICUs probably due to difference in knowledge and organizational factors. International and national guidelines should be better implemented. Despite of the high number of anesthesiologists reporting to apply palliative/supportive care to critically ill patients, clinicians, health care directions and health care providers might take these data into account to homogenize assessment and management of EOL patients admitted to ICU, providing a place where patients may be adequately treated according to a palliative care model and peacefully. Further research is also needed to compare practice among different countries.