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Diagnosing pulmonary embolism in pregnancy: Is there a role for D-dimer as a stand-alone test?

To the Editor: Giacomini and colleagues (1) conclude their interesting review of decision tools for life support by questioning to what extent such tools affect actual decisions taken because the effect of the various types of document (guidelines, recommendations, etc.) has not been well evaluated. The reality of end-of-life choices in an intensive care unit (ICU) is a complex mosaic, and it is by no means easy to formulate an answer to this question. However, one aspect—one fragment of the mosaic—that may be worth noting emerges from two different European studies on end-of-life decisions. Both studies, one Scandinavian (2) and the other Italian (3), have highlighted a significant degree of ignorance of the existence of guidelines in such a critical area of ICU practice. The first study showed that 29% of physicians had no knowledge of any written guidelines on triage and the withholding and withdrawal of intensive care. Nevertheless, the study found that ICU physicians generally act in broad conformity with guidelines, despite having little familiarity with actual documents. The second study found that only 3% of ICU physicians referred to international guidelines on triage and the withholding and withdrawal of intensive care, and most (56%) were unaware of the existence of such guidelines. Data of this kind cannot fail to raise questions about the effect of life-support decision tools on actual clinical practice; it is perhaps not simply an issue of how users interpret and apply these tools but, first and foremost, a question of whether such tools are effective in reaching their intended recipients (ICU physicians) and, therefore, whether they are capable of promoting any real cultural growth on these matters, even before being suitable tools for helping and informing clinical activity. If we are to avoid the proliferation of brief, pragmatic schemas for decision making—attractive as they may be, but equally simplistic and lacking in ethical consideration—we need to identify strategies that can be effective in “intercepting” or getting through to physicians. Indubitably, guidelines and recommendations still have a valid role (3), but I believe that only a continuous and methodic program of training and education is capable of influencing attitudes and modifying practice. End-of-life decision making and care must be maintained and given more importance in the training curricula of ICU physicians (4), but end-of-life ethics must also become a specific area of competency, which needs to be improved and updated. On this subject, it is astonishing that in Italy, even after the recent reform of the regulations on specialization training in anesthesia and intensive care (5), these topics have no more than an extremely marginal role in the curriculum. The author has not disclosed any potential conflicts of interest.