Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

Charles L Sprung*, Bara Ricou, Christiane S Hartog, Paulo Maia, Spyros D Mentzelopoulos, Manfred Weiss, Phillip D Levin, Laura Galarza, Veronica de la Guardia, Joerg C Schefold, Mario Baras, Gavin M Joynt, Hans-Henrik Bülow, Georgios Nakos, Vladimir Cerny, Stephan Marsch, Armand R Girbes, Catherine Ingels, Orsolya Miskolci, Didier LedouxSudakshina Mullick, Maria G Bocci, Jakob Gjedsted, Belén Estébanez, Joseph L Nates, Olivier Lesieur, Roshni Sreedharan, Alberto M Giannini, Lucía Cachafeiro Fuciños, Christopher M Danbury, Andrej Michalsen, Ivo W Soliman, Angel Estella, Alexander Avidan

*Corresponding author af dette arbejde

Publikation: Bidrag til tidsskriftArtikelForskningpeer review


Importance: End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time.

Objective: To determine the changes in end-of-life practices in European ICUs after 16 years.

Design, Setting, and Participants: Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision.

Exposures: Comparison between the 1999-2000 cohort vs 2015-2016 cohort.

Main Outcomes and Measures: End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists.

Results: Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001).

Conclusions and Relevance: Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.

Sider (fra-til)1692-1704
Antal sider13
TidsskriftJAMA - Journal of the American Medical Association
Udgave nummer17
Tidlig onlinedato2 okt. 2019
StatusUdgivet - 5 nov. 2019


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