11 It is impossible to dissect out the differences between religion and culture as many religions were found in a specific geographical area, such as more Catholic physicians in the Southern countries. This effect has

also been seen in America where one study showed that Jewish physicians in Pennsylvania were less likely to withdraw support31 as compared to North American Jewish Inhibitors,research,lifescience,medical health care providers who were more willing to limit therapy.32 RELIGIOSITY Bulow et al.22 investigated the significant differences in end-of-life decisions between doctors, nurses, patients, and families who consider themselves actively religious and those who identify themselves as only affiliated to a religion. Physicians and nurses wanted less treatment (ICU admission, Inhibitors,research,lifescience,medical CPR, ventilation) than check details patients and family members.22 Religious respondents requested more treatment and were more in favor of prolonging life.22 Religious respondents were less likely to want euthanasia than those only affiliated

to a religion.22 Fervent belief in religion usually provides support for families and staff but may lead to significant conflict between staff and parents regarding Inhibitors,research,lifescience,medical end-of-life decisions. Brierley et al.33 reviewed end-of-life decisions in a pediatric intensive care unit. Of 203 cases in which withdrawal or limitation of treatment was recommended, agreement with family was achieved in 186 Inhibitors,research,lifescience,medical (92%). In 17 cases (8%), despite extensive discussions with medical teams and local support mechanisms, no agreement could be obtained. In 11 of these cases (65%), the family expressed explicit religious belief that divine intervention would provide a miracle cure and the medical predictions were wrong.33 OTHER FACTORS Azoulay et al.34 investigated end-of-life practices in 282 intensive care units in seven geographic areas around the world. Of 14,488 patients with available data, 92% did not have decisions to forgo life-saving treatments, Inhibitors,research,lifescience,medical and 8% did. Of the 1,239 patients with decisions

to limit therapies, 677 (55%) had treatment withheld, and 562 (45%) had treatment Bay 11-7085 withdrawn. As expected, limitations were made in the sickest ICU patients.34 Organizational factors seemed to play a role in limitations. For example, patients admitted from another hospital were more likely to have limitations. The presence of a full-time intensivist and availability of doctors on weekends decreased the limitations. Other factors influencing decisions were personal physician characteristics, experience, and gender, case-mix in the ICU, and co-morbidities of patients.34 SUMMARY End-of-life decisions occur daily in ICUs around the world. There are numerous factors affecting these decisions including geographical location,6,7,10 religion,11,12 and attitudes of caregivers, patients, and families.