TY - JOUR
T1 - Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study
AU - Avidan, A
AU - Sprung, Cl
AU - Schefold, Jc
AU - Ricou, B
AU - Hartog, Cs
AU - Nates, Jl
AU - Jaschinski, U
AU - Lobo, Sm
AU - Joynt, Gm
AU - Lesieur, O
AU - Weiss, M
AU - Antonelli, Massimo
AU - Bülow, Hh
AU - Bocci, Maria Grazia
AU - Robertsen, A
AU - Anstey, Mh
AU - Estébanez-Montiel, B
AU - Lautrette, A
AU - Gruber, A
AU - Estella, A
AU - Mullick, S
AU - Sreedharan, R
AU - Michalsen, A
AU - Feldman, C
AU - Tisljar, K
AU - Posch, M
AU - Ovu, S
AU - Tamowicz, B
AU - Demoule, A
AU - Ganz, Fd
AU - Pargger, H
AU - Noto, A
AU - Metnitz, P
AU - Zubek, L
AU - de la Guardia, V
AU - Danbury, Cm
AU - Szúcs, O
AU - Protti, A
AU - Filipe, M
AU - Simpson, Sq
AU - Green, C
AU - Giannini, Am
AU - Soliman, Iw
AU - Piras, C
AU - Caser, Eb
AU - Hache-Marliere, M
AU - Mentzelopoulos, Sd
PY - 2021
Y1 - 2021
N2 - 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 (14middot6%) 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<0middot001). Limitation of life-sustaining treatment occurred in 10 401 patients (11middot8% of 87 951 ICU admissions and 80middot9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44middot1%]), followed by withdrawing life-sustaining treatment (4680 [36middot4%]). More treatment withdrawing was observed in Northern Europe (1217 [52middot8%] of 2305) and Australia/New Zealand (247 [45middot7%] of 541) than in Latin America (33 [5middot8%] of 571) and Africa (21 [13middot0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0middot5%]). 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 (5middot1%). Failure of CPR occurred less frequently in Northern Europe (85 [3middot7%] of 2305), Australia/New Zealand (23 [4middot3%] of 541), and North America (78 [8middot5%] of 918) than in Africa (106 [65middot4%] of 162), Latin America (160 [28middot0%] of 571), and Southern Europe (590 [22middot5%] 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. Copyright (c) 2021 Elsevier Ltd. All rights reserved.
AB - 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 (14middot6%) 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<0middot001). Limitation of life-sustaining treatment occurred in 10 401 patients (11middot8% of 87 951 ICU admissions and 80middot9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44middot1%]), followed by withdrawing life-sustaining treatment (4680 [36middot4%]). More treatment withdrawing was observed in Northern Europe (1217 [52middot8%] of 2305) and Australia/New Zealand (247 [45middot7%] of 541) than in Latin America (33 [5middot8%] of 571) and Africa (21 [13middot0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0middot5%]). 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 (5middot1%). Failure of CPR occurred less frequently in Northern Europe (85 [3middot7%] of 2305), Australia/New Zealand (23 [4middot3%] of 541), and North America (78 [8middot5%] of 918) than in Africa (106 [65middot4%] of 162), Latin America (160 [28middot0%] of 571), and Southern Europe (590 [22middot5%] 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. Copyright (c) 2021 Elsevier Ltd. All rights reserved.
KW - N/A
KW - N/A
UR - http://hdl.handle.net/10807/304296
U2 - 10.1016/S2213-2600(21)00261-7
DO - 10.1016/S2213-2600(21)00261-7
M3 - Article
SN - 2213-2600
VL - 9
SP - 1101
EP - 1110
JO - The Lancet Respiratory Medicine
JF - The Lancet Respiratory Medicine
ER -