Palliative Care and Legal Aspects of Treatment Limitation Decisions in ICU: A Survey of Clinicians' Perceptions

INTRODUCTION In countries with patient/family autonomy-oriented end-of-life (EOL) legislation, published data indicate variation of healthcare professionals' awareness of the specific legal provisions and/or regulations enabling limitation of life-sustaining treatments. Furthermore, communication difficulties and/or uncertainties about the validity of previously recorded patient preferences (e.g. in the form of advance directives) may result in heterogenous application of pertinent EOL laws/regulations. This may include cases of poor compliance with, or even opposition to new laws.

The absence of accurate and in-depth EOL legal knowledge of clinicians may be associated with perceptions that applicable laws/regulations are either too restrictive or excessively "liberal" for the patient. Furthermore, critical care physicians and/or nurses may lack specific knowledge about palliative care. Accordingly, physicians/nurses may also not be aware of the palliative nature of their everyday practice or have a clear understanding of primary and specialist palliative care.

Given the above-mentioned knowledge gaps of healthcare professionals caring for critically ill patients, the investigators propose to conduct a Europewide, descriptive survey for intensive care unit (ICU) clinicians, primarily aimed at addressing the following questions: 1) "How much of ICU everyday practice is palliative care and how is it practiced?"; and 2) "How do clinicians perceive the medico-legal framework around therapy limitations, patient autonomy and prognostication discussions with patients and families?" In addition, this survey will enable the investigators to comparatively assess the perceived extent of ICU palliative care practice in the presence vs. absence of EOL legislation.

METHODS Study participants and protocol approval The target population of this descriptive, open survey will include ICU physicians and nurses working in at least 100 ICUs across 50 European countries and Israel. Each one of participating ICUs will be represented by one or more healthcare professionals, and the target convenience-sample size will amount to at least 500 respondents (see also below-provided statistical analysis plan). This survey study is part of the European Union-funded Enhancing Palliative Care in ICU (EPIC) project (Proposal number: 101137221; HORIZON-HLTH-2023-DISEASE-03-01). The study protocol has been approved by the Scientific Council of Evaggelismos Hospital, Athens, Greece.

Informed consent and data protection A similar methodology has been recently described. According to the Helsinki declaration, participation in research requires informed consent of the participant. According to Regulation 679/2016 {or General Data Protection regulation (GDPR) of the European Parliament and of the Council, "consent" of the data subject means any freely given, specific, informed and unambiguous indication of the data subject's wishes by which he or she, by a statement or by a clear affirmative action, signifies agreement to the processing of personal data relating to him or her." Participation in and completion of the current survey means that the participant accepts to share their knowledge on palliative care practice, EOL legislation and EOL practice in their country. The estimated time for survey completion is between 30 and 60 min.