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Caring for the Critically Ill Patient
August 13, 2003

End-of-Life Practices in European Intensive Care Units: The Ethicus Study

Author Affiliations

Author Affiliations: Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel (Dr Sprung); Department of Medicine, University College of London, London, England (Dr Cohen); Department of Anesthesiology, Orebro University Hospital, Orebro, Sweden, (Dr Sjokvist); Department of Social Medicine, Hadassah Hebrew University Medical Center, Jerusalem (Dr Baras); Department of Anesthesiology, University Hospital of Glostrup, Glostrup, Denmark (Dr Bulow); Department of Anesthesiology, South Karelia Central Hospital, Lappeenranta, Finland (Dr Hovilehto); Department of Anesthesiology and Intensive Care Medicine, University of Liege, Liege, Belgium (Dr Ledoux); Department of Anesthesiology, Herlev University Hospital, Herlev, Denmark (Dr Lippert); Department of Intensive Care, Hospital Geral Santo Antonio, Porto, Portugal (Dr Maia); Department of Intensive Care, Mater Hospital University College, Dublin, Ireland (Dr Phelan); Division for General and Surgical Intensive Care Medicine, University Hospital Innsbruck, Innsbruck, Austria (Dr Schobersberger); Department of Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden (Dr Wennberg); Critical Care Directorate, Southampton University Hospitals NHS Trust, Southampton, United Kingdom (Mr Woodcock). Dr Sjokvist is now with Huddinge University Hospital, Stockholm, Sweden.


Caring for the Critically Ill Patient Section Editor: Deborah J. Cook, MD, Consulting Editor, JAMA.

JAMA. 2003;290(6):790-797. doi:10.1001/jama.290.6.790

Context While the adoption of practice guidelines is standardizing many aspects of patient care, ethical dilemmas are occurring because of forgoing life-sustaining therapies in intensive care and are dealt with in diverse ways between different countries and cultures.

Objectives To determine the frequency and types of actual end-of-life practices in European intensive care units (ICUs) and to analyze the similarities and differences.

Design and Setting A prospective, observational study of European ICUs.

Participants Consecutive patients who died or had any limitation of therapy.

Intervention Prospectively defined end-of-life practices in 37 ICUs in 17 European countries were studied from January 1, 1999, to June 30, 2000.

Main Outcome Measures Comparison and analysis of the frequencies and patterns of end-of-life care by geographic regions and different patients and professionals.

Results Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%) had limitations of treatments (10% of admissions). Substantial intercountry variability was found in the limitations and the manner of dying: unsuccessful cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range, 0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range, 0%-19%). Shortening of the dying process was reported in 7 countries. Doses of opioids and benzodiazepines reported for shortening of the dying process were in the same range as those used for symptom relief in previous studies. Limitation of therapy vs continuation of life-sustaining therapy was associated with patient age, acute and chronic diagnoses, number of days in ICU, region, and religion (P<.001).

Conclusion The limiting of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors. Although shortening of the dying process is rare, clarity between withdrawing therapies and shortening of the dying process and between therapies intended to relieve pain and suffering and those intended to shorten the dying process may be lacking.