Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Nov 5;322(17):1692-1704.
doi: 10.1001/jama.2019.14608.

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

Charles L Sprung  1 , Bara Ricou  2 , Christiane S Hartog  3 , Paulo Maia  4 , Spyros D Mentzelopoulos  5 , Manfred Weiss  6 , Phillip D Levin  7 , Laura Galarza  8 , Veronica de la Guardia  1 , Joerg C Schefold  9 , Mario Baras  10 , Gavin M Joynt  11 , Hans-Henrik Bülow  12 , Georgios Nakos  13 , Vladimir Cerny  14 , Stephan Marsch  15 , Armand R Girbes  16 , Catherine Ingels  17 , Orsolya Miskolci  18 , Didier Ledoux  19 , Sudakshina Mullick  20 , Maria G Bocci  21 , Jakob Gjedsted  22 , Belén Estébanez  23 , Joseph L Nates  24 , Olivier Lesieur  25 , Roshni Sreedharan  26 , Alberto M Giannini  27 , Lucía Cachafeiro Fuciños  23 , Christopher M Danbury  28 , Andrej Michalsen  29 , Ivo W Soliman  30 , Angel Estella  31 , Alexander Avidan  1
Affiliations

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

Charles L Sprung et al. JAMA. .

Erratum in

  • Omitted Author Contributions.
    [No authors listed] [No authors listed] JAMA. 2019 Nov 5;322(17):1718. doi: 10.1001/jama.2019.17746. JAMA. 2019. PMID: 31688867 Free PMC article. No abstract available.

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.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Hartog reports receipt of grants to her institution from the German Federal Ministry of Education and Research (BMBF) via the Center for Sepsis Control and Care, German Innovations Funds/Federal Joint Committee, and the European Society of Intensive Care Medicine. Dr Schefold reports receipt of grants (all paid into departmental accounts) from Orion Pharma, Abbott Nutrition International, B. Braun Medical AG, CSEM AG, Edwards Lifesciences Services GmbH, Kenta Biotech, Maquet Critical Care AB, Omnicare Clinical Research AG, Nestle, Pierre Fabre Pharma AG, Pfizer, Bard Medica S.A., Abbott AG, Anandic Medical Systems, Pan Gas AG Healthcare, Bracco, Hamilton Medical AG, Fresenius Kabi, Getinge Group Maquet AG, Dräger AG, Teleflex Medical GmbH, Glaxo Smith Kline, Merck Sharp and Dohme AG, Eli Lilly and Company, Baxter, Astellas, Astra Zeneca, CSL Behring, Novartis, Covidien, and Nycomed outside the submitted work. No additional disclosures were reported.

Figures

Figure.
Figure.. Changes in End-of-Life Practices From 1999-2000 to 2015-2016 in 22 ICUs by European Region
Presented are percentages of end-of-life practices in 22 centers with randomization of center numbers. Circles indicate 1999-2000 data and squares indicate the 2015-2016 data. The intensive care units (ICUs) have been sorted by the 1999-2000 prevalues across all ICUs in ascending order. The same ICU number has been kept throughout. All graphs have varying orders depending on the sort (based from left to right on lowest to highest percentage of patients in 1999-2000). Two centers had 17 patients with active shortening of the dying process (data not shown).
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

    1. Sprung CL, Truog RD, Curtis JR, et al. . Seeking worldwide professional consensus on the principles of end-of-life care for the critically ill: the Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) study. Am J Respir Crit Care Med. 2014;190(8):855-866. doi:10.1164/rccm.201403-0593CC - DOI - PubMed
    1. Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med. 2015;41(9):1572-1585. doi:10.1007/s00134-015-3810-5 - DOI - PubMed
    1. Sprung CL, Cohen SL, Sjokvist P, et al. ; Ethicus Study Group . End-of-life practices in European intensive care units: the Ethicus Study. JAMA. 2003;290(6):790-797. doi:10.1001/jama.290.6.790 - DOI - PubMed
    1. Devictor DJ, Tissieres P, Gillis J, Truog R; WFPICCS Task Force on Ethics . Intercontinental differences in end-of-life attitudes in the pediatric intensive care unit: results of a worldwide survey. Pediatr Crit Care Med. 2008;9(6):560-566. doi:10.1097/PCC.0b013e31818d3581 - DOI - PubMed
    1. Council of Europe Guide on the decision-making process regarding medical treatment in end-of-life situations. https://www.coe.int/t/dg3/healthbioethic/conferences_and_symposia/Guide%.... Accessed August 30, 2018.