Journal Club - Recent Additions

October - 2019


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

Charles L. Sprung, Bara Ricou, Christiane S. Hartog, et al JAMA, 2019, online first October


End-of-life care (EOLC) is important and complex. It invites a spillover of science, personal identity, emotion, and medical folklore. It is done differently, by nation, region, unit, team.  

In 2003 Ethicus-1, conducted in 1999/2000 in 37 European ICUs, reported a range of practice, including frequency of practice for patients dying in ICU;

  • withholding life-prolonging therapies ranged from 16% to 70%
  • withdrawing life-prolonging therapies ranged from 5% to 69%
  • active shortening of the dying process ranged from 0% to 19%
  • failed cardiopulmonary resuscitation (CPR) ranged from 5% to 48%

Europe has changed in the ensuing decade - attitudes, laws, recommendations, and guidelines. Paternalism persists, although shared decision making is advocated. European public support for euthanasia and physician-assisted suicide has increased. However, the extent of change in EOLC across European ICUs remains unknown. 

This week, in 2019, Ethicus-2 study reports on what has changed, repeating their study in 2015-2016.

What did they do and find;

  • prospective observational study of 1785 patients who had limitations in life-prolonging therapies or died in 22 European ICUs in 2015-2016 vs data previously reported from the same ICUs in 1999-2000 (2807 patients)
  • Study Definitions for End-of-Life Categories - these are important to understand the study 
    • Withholding treatment—a decision was made not to start or increase a life-sustaining intervention, such as not to perform CPR if a patient had a cardiac arrest.
    • Withdrawing treatment—a decision was madeto actively stop a life-sustaining intervention presently being given, such as stopping a norepinephrine infusion being given for shock.
    • Active shortening of the dying process—a circumstance in which someone performed an act with the specific intent of shortening the dying process; these acts did not include withholding or withdrawing although withholding or withdrawing could occur prior to active shortening of the dying process.
    • Failed CPR—death despite ventilation and cardiac massage.
    • Brain death—documented cessation of cerebral function and meeting criteria for brain death.
    • A hierarchical categorization was used for the most active limitation if more than one occurred (active shortening of the dying process > withdrawing > withholding).
  • Results
    • More patients died with treatment limitations (withholding, withdrawing, active shortening) in 15/16 (89.7% vs 68.3%)
    • Less patients died without any limitations in 15/16(10.3% vs 31.7%).
    • ICUs changed between the study periods, with increased admission numbers, bed numbers, reduced mortality, and increased “ethical practice scores” (retrospective surgery of 12 variables relating to ethical EOLC).
    • End-of-life categories varied by region. In 2015-2016 vs 1999-2000, the significant decrease in failed CPR was prominent in the south (difference, −21.3% [95% CI, −24.6% to −18.0%]; P < .001), while witholding life-sustaining treatment exhibited a significant increase in the south (difference, 16.8% [95% CI, 11.6% to 22.0%]; P < .001). Withdrawing life-sustaining treatment significantly increased in all regions and was highest in the central region (difference, 15.7%, [95% CI, 11.3% to 20.1%]; P < .001).
    • Median time from ICU admission until first limitation was shorter in 2015-2016 compared with 1999-2000 (2.1 vs 4.0 days; P < .001), and the ICU length of stay was shorter in 2015- 2016 compared with 1999-2000 (4.0 vs 5.0 days; P < .001).
    • Survival to hospital discharge after any therapy limitation was higher in 2015-2016 (20.4%) vs 1999-2000 (5.5%)(difference, 14.9% [95% CI, 12.7% to 17.1%]; P < .001). The improved survival was higher after withholding mechanical ventilation (36.9% vs 11.5% [15]; difference, 25.5% [95% CI, 22.9% to 28.0%]; P < .001), withholding vasopressors (20.7% vs 4.6%, difference, 16.1% [95% CI, 14.1% to 18.2%]; P < .001), withholding renal replacement therapy (26.9% vs1.8%; difference, 25.1% [95% CI, 23.0% to 27.2%]; P < .001).

Overall, these findings suggest end-of-life care practices in European ICUs changed from 1999-2000 to 2015-2016. Patients who died were more likely to have limitations in life-prolonging therapies in place, these occurred earlier, and fewer patients died deaths without treatment limitations. ICUs reported improvement in self-reported “ethical practice”, and there has been an increase in palliative and patient-centred care from government to bedside. Survival after treatment limitation improved. This is not surprising, as more progressive, inclusive end-of-life care identified patients who are not imminently dying, allowing decisions about less invasive care to be made weeks to months before death. Active or assisted dying is uncommon.

Patient or surrogate voice is not reported in this study, with capture of values and goals and alignment of care to them, an ongoing challenge in the measurement of quality of ICU end of life care. 

This is a tremendous amount of work, gives us hope about the direction of EOLC in ICU, and provides impetus to continue to improve.



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.


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