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

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  • Charles L. Sprung, Hebrew University of Jerusalem
  • ,
  • Bara Ricou, Geneva University Hospital
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  • Christiane S. Hartog, Charité-Universitätsmedizin Berlin
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  • Paulo Maia, Hospital S. Antonio
  • ,
  • Spyros D. Mentzelopoulos, Evaggelsimos General Hospital
  • ,
  • Manfred Weiss, University Hospital Medical School, Ulm
  • ,
  • Phillip D. Levin, Shaare Zedek Medical Center
  • ,
  • Laura Galarza, Hospital General Universitario de Castellón
  • ,
  • Veronica De La Guardia, Hebrew University of Jerusalem
  • ,
  • Joerg C. Schefold, University of Bern
  • ,
  • Mario Baras, Hebrew University of Jerusalem
  • ,
  • Gavin M. Joynt, Chinese University Hong Kong
  • ,
  • Hans Henrik Bülow, Holbaek University Hospital
  • ,
  • Georgios Nakos, University of Ioannina
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  • Vladimir Cerny, Jan Evangelista Purkyne University in Usti nad Labem
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  • Stephan Marsch, University of Basel
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  • Armand R. Girbes, Vrije Universiteit Amsterdam
  • ,
  • Catherine Ingels, KU Leuven
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  • Orsolya Miskolci, Mater Misericordiae University Hospital
  • ,
  • Didier Ledoux, University of Liege
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  • Sudakshina Mullick, Tata Medical Center
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  • Maria G. Bocci, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Università Cattolica del Sacro Cuore
  • ,
  • Jakob Gjedsted
  • Belén Estébanez, University Hospital La Paz
  • ,
  • Joseph L. Nates, University of Texas MD Anderson Cancer Center
  • ,
  • Olivier Lesieur, Hôpital Saint-Louis
  • ,
  • Roshni Sreedharan, Cleveland Clinic
  • ,
  • Alberto M. Giannini, Spedali Civili Di Brescia
  • ,
  • Lucía Cachafeiro Fuciños, University Hospital La Paz
  • ,
  • Christopher M. Danbury, Royal Berkshire Hospital
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  • Andrej Michalsen, Medizin Campus Bodensee - Tettnang Hospital
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  • Ivo W. Soliman, Utrecht University
  • ,
  • Angel Estella, University Hospital SAS of Jerez
  • ,
  • Alexander Avidan, Hebrew University of Jerusalem
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.
OriginalsprogEngelsk
TidsskriftJAMA - Journal of the American Medical Association
Vol/bind322
Nummer17
Sider (fra-til)1692-1704
Antal sider13
ISSN0098-7484
DOI
StatusUdgivet - nov. 2019

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