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
