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Original Investigation
Caring for the Critically Ill Patient
October 2, 2019

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

Author Affiliations
  • 1Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
  • 2Department of Anesthesiology, Pharmacology, and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
  • 3Department of Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin and Klinik Bavaria, Kreischa, Germany
  • 4Intensive Care Department, Hospital S. Antonio, Centro Hospitalar do Porto, Porto, Portugal
  • 5First Department of Intensive Care Medicine, University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
  • 6Clinic of Anaesthesiology, University Hospital Medical School, Ulm, Germany
  • 7General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
  • 8Intensive Care Unit, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
  • 9Inselspital, Department of Intensive Care Medicine, University of Bern, Switzerland
  • 10The Hebrew University—Hadassah School of Public Health, Jerusalem, Israel
  • 11Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
  • 12Department of Anesthesiology and Intensive Care, Holbaek University Hospital, Zealand Region, Denmark
  • 13Department of Intensive Care Medicine, University of Ioannina, Ioannina, Greece
  • 14Department of Anesthesiology, Perioperative Medicine, and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Czech Republic
  • 15Medical Intensive Care, University of Basel Hospital, Basel, Switzerland
  • 16Department of Intensive Care Medicine, VU Medical Center, Amsterdam, the Netherlands
  • 17Intensive Care Medicine, University Hospitals K.U. Leuven, Leuven Belgium
  • 18Mater Misericordiae University Hospital, Intensive Care Unit, Dublin, Ireland
  • 19Department of Anesthesiology and Intensive Care Medicine, University of Liege, Liege, Belgium
  • 20Critical Care Medicine,Tata Medical Center, Kolkata, India
  • 21Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
  • 22Department of Anesthesia and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
  • 23Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
  • 24Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston
  • 25Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
  • 26Department of General Anesthesiology, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
  • 27Division of Pediatric Anesthesia and Intensive Care, ASST Spedali Civili, Brescia, Italy
  • 28Department of Intensive Care, Royal Berkshire Hospital, Berkshire, United Kingdom
  • 29Department of Anesthesiology and Critical Care, Medizin Campus Bodensee-Tettnang Hospital, Tettnang, Germany
  • 30Department of Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands
  • 31Intensive Care Department, University Hospital SAS of Jerez, Jerez de la Frontera, Spain
JAMA. 2019;322(17):1692-1704. doi:10.1001/jama.2019.14608
Key Points

Question  Have end-of-life practices in European intensive care units (ICUs) changed from 1999-2000 to 2015-2016?

Findings  In 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%).

Meaning  These 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.


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.