Decision-making at the end-of-life in the United States has evolved over the last 50 yr, beginning with the development of the concept of brain death as a criterion for permitting patients who are in a state of ‘irreversible coma’ to be considered as ‘dead’ for purposes of ventilator withdrawal and organ transplantation. Since then, a firm consensus has emerged in American law and ethics that ‘Patients have a virtually unlimited right to refuse any unwanted medical treatment, even if necessary for life itself.’ With regard to patients who are unable to make decisions for themselves, both Europe and the United States are converging toward a view that respects a role for surrogates in decision-making while recognizing the need to limit their authority. Beyond decisions to withdraw and withhold treatments, both the United States and Europe are experimenting with active hastening of the dying process through euthanasia and physician-assisted suicide. In the author’s opinion, the next big question to be addressed in end-of-life decision-making is ‘Just how bad does the neurological condition and prognosis need to be before it is acceptable to allow a decision to withdraw life support’? Although the practices described here have wide acceptance throughout the United States and Europe, the worldwide emergence of religious fundamentalism and the associated vitalistic view about the sanctity of life may result in significant changes over the next few decades.

Nurses have become independent over the last few decades in Italy, thanks to a series of legislative changes. When dealing with organ donation, the nurses usually face unexpected and complex situations from both a technical and interpersonal point of view. When the death of a loved one has to be communicated to the family, the coordinator nurse, along with the doctor, talks with the relatives to help them decide whether or not to donate organs. It is fundamental that the death of the patient is communicated by the doctor in charge of the case and this has to be done before the question of donation is raised. The idea of donation is suggested when we believe the family has understood that their beloved is dead. We try to adapt our communication style to the background of the family. Experience has shown us that these situations are emotionally complex and tiring for both the family members and health workers. Sometimes the stress level amongst health workers is so high that psychological support is needed after the interview. If the family decides to donate, the restitution phase is very important. A meeting is organized for a month after the event to inform the relatives of the success of donation.

Summary

Background and objectives: The American Heart Association guidelines from 2000 recommend that family members be allowed to witness cardiopulmonary resuscitation. This is controversial and opponents fear litigation and family interference during family witnessed resuscitation (FWR). The extent of FWR in UK Emergency Departments is unknown.

Methods: A telephone survey of a selection of UK Emergency Departments was performed asking about experience with FWR.

Results: One-hundred-and-sixty-two UK Emergency Departments with an average attendance of 47 000 patients per year participated. FWR was allowed by 128 (79%) for an adult patient and 93% for a child. Of these, 50% invited relatives to witness and only 21% did not permit FWR. The perceived benefits were: accepting that all possible has been done (48%), accepting the death (48%) and help with grieving (38%). Two percent did not think FWR was of help. Few had encountered any problems or interference from the family. Never being asked was the commonest reason not allowing FWR followed by staff reluctance. Most respondents would wish to be present if their child (85%), spouse/partner (64%) or elderly relative (52%) was being resuscitated.

Conclusions: FWR is common in UK Emergency Departments. It is more common when children are being resuscitated than adults. Further research is needed to demonstrate whether it is of benefit to the patient or relatives and its applicability to other areas such as intensive care.