Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016
Authors: Charles L. Sprung, Bara Ricou, Christiane S. Hartog, Paulo Maia, Spyros D. Mentzelopoulos, Manfred Weiss, Phillip D. Levin, Laura Galarza, Veronica de la Guardia, Joerg C. Schefold, Mario Baras, Gavin M. Joynt, Hans-Henrik Bülow, Georgios Nakos, Vladimir Cerny, Stephan Marsch, Armand R. Girbes, Catherine Ingels, Orsolya Miskolci, Didier Ledoux, Sudakshina Mullick, Maria G. Bocci, Jakob Gjedsted, Belén Estébanez, Joseph L. Nates, Olivier Lesieur, Roshni Sreedharan, Alberto M. Giannini, Lucía Cachafeiro Fuciños, Christopher M. Danbury, Andrej Michalsen, Ivo W. Soliman, Angel Estella, Alexander Avidan
Journal: JAMA (2019)

<h3>Importance</h3> End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time. <h3>Objective</h3> To determine the changes in end-of-life practices in European ICUs after 16 years. <h3>Design, Setting, and Participants</h3> 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. <h3>Exposures</h3> Comparison between the 1999-2000 cohort vs 2015-2016 cohort. <h3>Main Outcomes and Measures</h3> 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. <h3>Results</h3> 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];<i>P</i> &lt; .001) and the proportion of female patients was similar (39.6% vs 38.7%;<i>P</i> = .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%];<i>P</i> &lt; .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%];<i>P</i> &lt; .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%];<i>P</i> &lt; .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, −16.2% [95% CI, −18.1% to −14.3%];<i>P</i> &lt; .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, −5.2% [95% CI, −6.6% to −3.8%];<i>P</i> &lt; .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, −1.9% [95% CI,<b>−</b>2.7% to −1.1%];<i>P</i> &lt; .001). <h3>Conclusions and Relevance</h3> 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.