@article{3187543,
    title = "Changes in End-of-Life Practices in European Intensive Care Units From
1999 to 2016",
    author = "Sprung, Charles L. and Ricou, Bara and Hartog, Christiane S. and Maia, and Paulo and Mentzelopoulos, Spyros D. and Weiss, Manfred and Levin, and Phillip D. and Galarza, Laura and de la Guardia, Veronica and Schefold, and Joerg C. and Baras, Mario and Joynt, Gavin M. and Bulow, Hans-Henrik and and Nakos, Georgios and Cerny, Vladimir and Marsch, Stephan and Girbes, and Armand R. and Ingels, Catherine and Miskolci, Orsolya and Ledoux, Didier and and Mullick, Sudakshina and Bocci, Maria G. and Gjedsted, Jakob and and Estebanez, Belen and Nates, Joseph L. and Lesieur, Olivier and and Sreedharan, Roshni and Giannini, Alberto M. and Cachafeiro Fucinos, and Lucia and Danbury, Christopher M. and Michalsen, Andrej and Soliman, Ivo and W. and Estella, Angel and Avidan, Alexander",
    journal = "JAMA - JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION - INTERNATIONAL EDITION",
    year = "2019",
    volume = "322",
    number = "17",
    pages = "1692-1704",
    publisher = "AMER MEDICAL ASSOC",
    issn = "0098-7484",
    doi = "10.1001/jama.2019.14608",
    abstract = "Key PointsQuestionHave end-of-life practices in European intensive care
units (ICUs) changed from 1999-2000 to 2015-2016? FindingsIn this
prospective observational study of 1785 patients who had limitations in
life-prolonging therapies or died in 22 European ICUs in 2015-2016,
compared with data previously reported from the same ICUs in 1999-2000
(2807 patients), treatment limitations (withholding or withdrawing
life-sustaining treatment or active shortening of the dying process)
occurred significantly more frequently (89.7\% vs 68.3\%), whereas death
without any limitations in life-prolonging therapies occurred
significantly less frequently (10.3\% vs 31.7\%). MeaningThese findings
suggest that end-of-life care practices in European ICUs changed from
1999-2000 to 2015-2016 with more limitations in life-prolonging
therapies and fewer deaths without treatment limitations.
ImportanceEnd-of-life decisions occur daily in intensive care units
(ICUs) around the world, and these practices could change over time.
ObjectiveTo determine the changes in end-of-life practices in European
ICUs after 16 years. Design, Setting, and ParticipantsEthicus-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.
ExposuresComparison between the 1999-2000 cohort vs 2015-2016 cohort.
Main Outcomes and MeasuresEnd-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.
ResultsOf 13625 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 RelevanceAmong 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.
This study compares changes in end-of-life practices (withholding or
withdrawing of life-prolonging therapy, active shortening of the dying
process, failed CPR, documentation of brain death) in 22 European ICUs
between 1999-2000 and 2015-2016."
}