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June 28, 2016


Examining the socioeconomic factors


Decisions surrounding end of life and treat limitation orders of critically ill patients are influenced by a number of factors.  Socioeconomic factors are likely to play a significant role. Little is known about the differences between low-middle income countries and high income countries. The Asian Collaboration for Medical Ethics (ACME) has conducted a qualitative study to investigate this. 

An online questionnaire study was conducted in 2012. Perceptions surrounding difficult situations with patients and families, which were likely to result in conflict, were studied in a survey. The economic status of the countries was defined based on the 2012 World Bank classification, which was based on gross national income per capita.  255 of 508 invited ICUs (50.2 %) and 847 of 1355 invited physicians (62.5 %) participated from 10 low-middle income countries and regions.  211 of 277 invited ICUs (76.2 %) and 618 of 1105 invited physicians (55.9 %) participated from six high-income countries and region

Decision-making for withholding and withdrawal of life-sustaining treatments saw slightly more involvement from ICU physicians and families in low-middle-income countries compared to high-income countries. Similarly, there was more involvement from ICU nurses and primary physicians outside the ICU in high-income countries compared to low-middle income countries. Physicians with religious beliefs were less likely to withhold cardiopulmonary resuscitation in end-of-life care compared with those physicians without religious beliefs, when unadjusted associations were assessed.

“Despite less financial resources, ICU physicians from low-middle income Asian countries are less likely to limit cardiopulmonary resuscitation, and life-sustaining treatments than those from high income countries and regions”. 

Perhaps unsurprisingly, the expected financial burden for patients and institutions had a greater impact on decision making among physicians from low-middle income countries compared to high income countries. Despite less financial resources, ICU physicians from low-middle income Asian countries are less likely to limit cardiopulmonary resuscitation, and life-sustaining treatments than those from high income countries and regions. However, in the hypothetical event that a patient with a reasonable chance of recovery has escalating medical bills, physicians in low-middle countries are more likely to agree to cessation of life sustaining treatment. Patient and family funded healthcare expenditure exceeded 30% of the total healthcare expenditure in all but one of the low-middle-income countries. It is therefore unsurprising that decision-making may seem more family centered rather than patient centered, and the decision to limit treatment based on financial grounds is more common in low-middle income Asian countries.

The perception of inappropriate requests for life-sustaining treatments was significantly higher among respondents from low-middle income countries though they were more comfortable in discussing limitation of life-sustaining treatments with patients, families and surrogates. Active withdrawal of life sustaining treatment was seen as a greater risk to legal consequences among both low-middle and high income countries. Overall, only a minority of countries had written policies for limitation of life-sustaining treatments (12.9 vs. 22.5 % in middle income countries and high income countries respectively; p < 0.001). The maturity of palliative care services within a country influence decision-making as the integration of palliative care with critical care services has led to more limitation of life-sustaining treatments. In addition to this, the legal framework surrounding limitation and withdrawal of life-sustaining treatments seems to be less clearly defined in low-middle income Asian countries. Consequently, physicians in these countries feel more open to legal risks and want explicit guidelines.

This study gleans important information on the effect of the impact of national economics on healthcare practices in ICU. The complex interplay between social, cultural, religious, legal, and financial factors ultimately determine how physicians respond to patients and relatives in a specific clinical context. The authors conclude that the “overall aim is to facilitate a more coherent, humane and cost-effective approach to the management of dying patients” where “resources are spent on saving lives rather than prolonging deaths”.

Article review submitted by Nisharu Arulkumaran on behalf of the NEXT Committee.


Phua J, Joynt GM, Nishimura M, Deng Y, Myatra SN, Chan YH, Binh NG, Tan CC, Faruq MO, Arabi YM, Wahjuprajitno B, Liu SF, Hashemian SM, Kashif W, Staworn D, Palo JE, Koh Y; ACME Study Investigators; Asian Critical Care Clinical Trials Group. Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions. Intensive Care Med. 2016 Jul;42(7):1118-27. doi: 10.1007/s00134-016-4347-y. Epub 2016 Apr 12.

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