C22-16 Who Decides at the End of Life? Gender and Surrogate Roles in a Muslim ICU Cohort

Introduction Because most intensive care unit (ICU) patients lack decision-making capacity when resuscitation and life-sustaining treatments are considered, surrogates often decide. In Western settings, in the absence of advance directives, spouses usually serve in this role, followed by adult children. In Muslim societies, decision-making has been described as male-dominated, with sons or male relatives often guiding key medical decisions. Whether these patterns extend to ICU end-of-life (EOL) goals of care discussions in Muslim-majority contexts is unknown. Methods We conducted a prospective observational study in the 31-bed tertiary ICU at King Faisal Specialist Hospital & Research Centre, Jeddah. From August 2021 to July 2023, all married Muslim adult ICU patients with a living spouse at the time of goals-of-care discussion were included. As advance directives are not recognized in the Saudi medicolegal system, surrogate decision-making is documented by treating physicians. The identity of the decision-maker was prospectively recorded on standardized DNAR forms or clinical notes. Data were abstracted into a study database and verified with chart review. Patients were stratified by gender, and comparisons were made for primary decision-maker, number of family members present during discussions, and transition to do-not-attempt-resuscitation (DNAR). Statistical comparisons were performed using chi-square or Fisher’s exact tests as appropriate. Results Of 176 eligible patients, 144 (82%) were male and 32 (18%) female. Mean age was lower among women than men (53 vs. 61 years, p = 0.005). Spouses were significantly more likely to serve as decision-makers for women than for men (56% vs. 28%, p = 0.001). Among women, sons were the second most frequent surrogates (38%), whereas other relatives were rarely primary (6%). For men, by contrast, sons (40%) and other relatives (32%) more often assumed this role, with the spouse identified in only 28%. Code status was discussed with a single family member in roughly half of cases (49% men vs. 56% women, p = 0.47); the remainder involved two or more relatives. Despite these gendered patterns in decision-making, transition to do-not-attempt-resuscitation (DNAR) was very common and nearly identical between groups (87% vs. 88%, p = 0.92). Conclusion In this Saudi tertiary ICU study, surrogate decision-making differed by patient gender. Spouses most often acted for women, whereas sons and other relatives more often did so for men, yet transitions to do-not-attempt-resuscitation (DNAR) were similar. These findings illustrate the influence of gendered family roles on end-of-life decisions in a Muslim-majority setting without advance directives. This abstract is funded by: None