@article{3031719,
    title = "Variations in end-of-life practices in intensive care units worldwide
(Ethicus-2): a prospective observational study",
    author = "Avidan, Alexander and Sprung, Charles L. and Schefold, Joerg C. and and Ricou, Bara and Hartog, Christiane S. and Nates, Joseph L. and and Jaschinski, Ulrich and Lobo, Suzana M. and Joynt, Gavin M. and Lesieur, and Olivier and Weiss, Manfred and Antonelli, Massimo and Bulow, Hans-Henrik and and Bocci, Maria G. and Robertsen, Annette and Anstey, Matthew H. and and Estebanez-Montiel, Belen and Lautrette, Alexandre and Gruber, Anastasiia and and Estella, Angel and Mullick, Sudakshina and Sreedharan, Roshni and and Michalsen, Andrej and Feldman, Charles and Tisljar, Kai and Posch, and Martin and Ovu, Steven and Tamowicz, Barbara and Demoule, Alexandre and and Ganz, Freda DeKeyser and Pargger, Hans and Noto, Alberto and Metnitz, and Philipp and Zubek, Laszlo and de la Guardia, Veronica and Danbury, and Christopher M. and Szucs, Orsolya and Protti, Alessandro and Filipe, and Mario and Simpson, Steven Q. and Green, Cameron and Giannini, Alberto M. and and Soliman, Ivo W. and Piras, Claudio and Caser, Eliana B. and and Hache-Marliere, Manuel and Mentzelopoulos, Spyros and ETHICUS 2 Study and Grp",
    journal = "The Lancet Respiratory Medicine",
    year = "2021",
    volume = "9",
    number = "10",
    pages = "1101-1110",
    publisher = "Elsevier Sci Ltd, Exeter, United Kingdom",
    issn = "2213-2600",
    doi = "10.1016/S2213-2600(21)00261-7",
    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 (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."
}