Décisions de limitation ou d'arrêt des thérapeutiques actives dans les services d'urgence

A growing number of patients die each year in the Emergency Department (ED). These deaths are often preceded by decisions to withhold or withdraw life-sustaining treatments but few studies have focused on decisions to limit life-support in the ED. Withdrawing and withholding life-support therapy involved elderly patients with underlying chronic cardiopulmonary disease or metastatic cancer or patients with acute non-treatable illness. Resuscitation procedures are instituted for 80% of patients before a subsequent decision to withhold or withdraw life-sustaining therapy. Conditions of the decision-making process are globally unsatisfactorily because a lonely physician take this decision on his own in about 20% of the cases, nursing staff is not always implicated and family is not always informed of such a decision. French emergency and critical care societies (Société de Réanimation de Langue Française and Société Française de Médecine d'Urgence) have released recommandations about such decisions. They are based on ethical principles of autonomy, best interest of the patient, absence of futility of care. Emergency medical teams may enhance quality of care for this particular population by the following actions: constitution of a multidisciplinary group motivated by this ethical problem, production of procedures adapted from societies' recommandations to local conditions, production of a standardised form on which decisions to withhold or withdraw life-sustaining treatments can be written and inserted in the medical file. Emergency medical teams have to adapt their organization to this new population because this strong sociological fact will be present for years.