Charles L Sprung1, Bara Ricou2, Christiane S Hartog3, Paulo Maia4, Spyros D Mentzelopoulos5, Manfred Weiss6, Phillip D Levin7, Laura Galarza8, Veronica de la Guardia1, Joerg C Schefold9, Mario Baras10, Gavin M Joynt11, Hans-Henrik Bülow12, Georgios Nakos13, Vladimir Cerny14, Stephan Marsch15, Armand R Girbes16, Catherine Ingels17, Orsolya Miskolci18, Didier Ledoux19, Sudakshina Mullick20, Maria G Bocci21, Jakob Gjedsted22, Belén Estébanez23, Joseph L Nates24, Olivier Lesieur25, Roshni Sreedharan26, Alberto M Giannini27, Lucía Cachafeiro Fuciños23, Christopher M Danbury28, Andrej Michalsen29, Ivo W Soliman30, Angel Estella31, Alexander Avidan1. 1. Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel. 2. Department of Anesthesiology, Pharmacology, and Intensive Care, University Hospital of Geneva, Geneva, Switzerland. 3. Department of Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin and Klinik Bavaria, Kreischa, Germany. 4. Intensive Care Department, Hospital S. Antonio, Centro Hospitalar do Porto, Porto, Portugal. 5. First Department of Intensive Care Medicine, University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece. 6. Clinic of Anaesthesiology, University Hospital Medical School, Ulm, Germany. 7. General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel. 8. Intensive Care Unit, Hospital General Universitario de Castellón, Castellón de la Plana, Spain. 9. Inselspital, Department of Intensive Care Medicine, University of Bern, Switzerland. 10. The Hebrew University-Hadassah School of Public Health, Jerusalem, Israel. 11. Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China. 12. Department of Anesthesiology and Intensive Care, Holbaek University Hospital, Zealand Region, Denmark. 13. Department of Intensive Care Medicine, University of Ioannina, Ioannina, Greece. 14. Department of Anesthesiology, Perioperative Medicine, and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Czech Republic. 15. Medical Intensive Care, University of Basel Hospital, Basel, Switzerland. 16. Department of Intensive Care Medicine, VU Medical Center, Amsterdam, the Netherlands. 17. Intensive Care Medicine, University Hospitals K.U. Leuven, Leuven Belgium. 18. Mater Misericordiae University Hospital, Intensive Care Unit, Dublin, Ireland. 19. Department of Anesthesiology and Intensive Care Medicine, University of Liege, Liege, Belgium. 20. Critical Care Medicine,Tata Medical Center, Kolkata, India. 21. Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. 22. Department of Anesthesia and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark. 23. Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain. 24. Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston. 25. Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France. 26. Department of General Anesthesiology, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio. 27. Division of Pediatric Anesthesia and Intensive Care, ASST Spedali Civili, Brescia, Italy. 28. Department of Intensive Care, Royal Berkshire Hospital, Berkshire, United Kingdom. 29. Department of Anesthesiology and Critical Care, Medizin Campus Bodensee-Tettnang Hospital, Tettnang, Germany. 30. Department of Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands. 31. Intensive Care Department, University Hospital SAS of Jerez, Jerez de la Frontera, Spain.
Abstract
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.
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.
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