Alexander Avidan1, Charles L Sprung2, Joerg C Schefold3, Bara Ricou4, Christiane S Hartog5, Joseph L Nates6, Ulrich Jaschinski7, Suzana M Lobo8, Gavin M Joynt9, Olivier Lesieur10, Manfred Weiss11, Massimo Antonelli12, Hans-Henrik Bülow13, Maria G Bocci12, Annette Robertsen14, Matthew H Anstey15, Belén Estébanez-Montiel16, Alexandre Lautrette17, Anastasiia Gruber18, Angel Estella19, Sudakshina Mullick20, Roshni Sreedharan21, Andrej Michalsen22, Charles Feldman23, Kai Tisljar24, Martin Posch18, Steven Ovu6, Barbara Tamowicz25, Alexandre Demoule26, Freda DeKeyser Ganz27, Hans Pargger24, Alberto Noto28, Philipp Metnitz29, Laszlo Zubek30, Veronica de la Guardia1, Christopher M Danbury31, Orsolya Szűcs32, Alessandro Protti33, Mario Filipe34, Steven Q Simpson35, Cameron Green36, Alberto M Giannini37, Ivo W Soliman38, Claudio Piras39, Eliana B Caser40, Manuel Hache-Marliere41, Spyros D Mentzelopoulos42. 1. Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel. 2. Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel. Electronic address: charles.sprung@ekmd.huji.ac.il. 3. Inselspital, Department of Intensive Care Medicine, University of Bern, Bern, Switzerland. 4. Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland. 5. Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany, and Klinik Bavaria, Kreischa, Germany. 6. Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. 7. Department of Anesthesiology and Critical Care Medicine, University Hospital Augsburg, Augsburg, Germany. 8. Intensive Care Division, São José do Rio Preto School of Medicine, São Jose do Rio Preto, São Paulo, Brazil. 9. Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong. 10. Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France. 11. Clinic of Anaesthesiology and Intensive Care Medicine, University Hospital Medical School, Ulm, Germany. 12. Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy. 13. Department of Anesthesiology and Intensive Care, Holbaek University Hospital, Zealand Region, Denmark. 14. Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway. 15. Sir Charles Gairdner Hospital, Perth, WA, Australia. 16. Intensive Care Department, University Hospital La Paz, Madrid, Spain. 17. Medical Intensive Care Unit, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France. 18. Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria. 19. Intensive Care Department, University Hospital SAS of Jerez, Jerez de la Frontera, Spain. 20. Critical Care Medicine, Tata Medical Center, Kolkata, India. 21. Department of General Anesthesiology, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA. 22. Department of Anesthesiology and Critical Care, Medizin Campus Bodensee-Tettnang Hospital, Tettnang, Germany. 23. Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. 24. Intensive Care Unit, University Hospital and University of Basel, Basel, Switzerland. 25. Faculty of Health Sciences, Poznan University of Medical Sciences, Poznań, Poland. 26. Service de Médecine intensive- Réanimation, AP-HP Sorbonne Université, Site Pitié-Salpêtrière, and UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, Paris, France. 27. Hadassah Hebrew University School of Nursing and Jerusalem College of Technology, Faculty of Life and Health Sciences, Jerusalem, Israel. 28. Department of Human Pathology of the Adult and Evolutive Age "Gaetano Barresi", Division of Anesthesia and Intensive Care, University of Messina, Messina, Italy. 29. Department of General Anaesthesiology, Emergency and Intensive Care Medicine, LKH-University Hospital of Graz, Graz, Austria. 30. Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary. 31. Department of Intensive Care, Royal Berkshire Hospital, Berkshire, UK. 32. 1st Department of Surgery and Interventional Gastroenterology, Semmelweis University, Budapest, Hungary. 33. Department of Anesthesia, Intensive Care, and Emergency Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy. 34. Department of Anesthesiology and Critical Care Medicine, DPC Hospital Budapest, Semmelweis University, Budapest, Hungary. 35. Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas, Kansas City, KS, USA. 36. Department of Intensive Care, Peninsula Health, Melbourne, VIC, Australia. 37. Division of Pediatric Anesthesia and Intensive Care, ASST-Spedali Civili, Brescia, Italy. 38. Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands. 39. Vitória Apart Hospital, Serra-ES, Brazil. 40. Department of Internal Medicine, University Federal do Espírito Santo, Espírito Santo, Brazil. 41. Department of Critical Care Medicine, CEDIMAT, Santo Domingo, Dominican Republic, and Department of Internal Medicine, Jacobi Medical Center-AECOM, Bronx, NY, USA. 42. First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece.
Abstract
BACKGROUND: End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS: In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS: Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. INTERPRETATION: Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. FUNDING: None.
BACKGROUND: End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS: In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS: Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. INTERPRETATION: Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. FUNDING: None.
Authors: Bernhard Wernly; Richard Rezar; Hans Flaatten; Michael Beil; Jesper Fjølner; Raphael R Bruno; Antonio Artigas; Bernardo B Pinto; Joerg C Schefold; Malte Kelm; Sviri Sigal; Peter V van Heerden; Wojciech Szczeklik; Muhammed Elhadi; Michael Joannidis; Sandra Oeyen; Georg Wolff; Brian Marsh; Finn H Andersen; Rui Moreno; Susannah Leaver; Sarah Wernly; Ariane Boumendil; Dylan W De Lange; Bertrand Guidet; Christian Jung Journal: J Intern Med Date: 2022-04-22 Impact factor: 13.068
Authors: Suzana M Lobo; Claire J Creutzfeldt; Israel S Maia; James A Town; Edilberto Amorim; Erin K Kross; Başak Çoruh; Pratik V Patel; Gemi E Jannotta; Ariane Lewis; David M Greer; J Randall Curtis; Monisha Sharma; Sarah Wahlster Journal: Chest Date: 2022-02-10 Impact factor: 10.262
Authors: Spyros D Mentzelopoulos; Su Chen; Joseph L Nates; Jacqueline M Kruser; Christiane Hartog; Andrej Michalsen; Nikolaos Efstathiou; Gavin M Joynt; Suzana Lobo; Alexander Avidan; Charles L Sprung Journal: Crit Care Date: 2022-04-13 Impact factor: 9.097
Authors: Lama H Nazer; Maria A Lopez-Olivo; Anne Rain Brown; John A Cuenca; Michael Sirimaturos; Khader Habash; Nada AlQadheeb; Heather May; Victoria Milano; Amy Taylor; Joseph L Nates Journal: Crit Care Explor Date: 2022-09-13