A large multinational prospective observational study examined how patient age influences end-of-life practices in ICUs worldwide. Conducted as part of the ETHICUS-2 project, the study addresses a key gap in global evidence by analysing whether and how age affects decisions to limit life-sustaining therapy (LST), including withholding, withdrawing, or actively shortening the dying process.
The study included 12,200 adult ICU patients from 199 ICUs across 36 countries who either died or had limitations placed on LST during a six-month period between September 2015 and September 2016. Patients were categorised into three age groups: under 65 years, 65–79 years, and 80 years or older. The primary outcome was whether a patient underwent any LST limitation, while secondary outcomes included types of limitations and reasons for these decisions.
The findings demonstrate a clear association between increasing age and the likelihood of LST limitation. Patients aged 80 years or older had significantly higher odds of experiencing any limitation compared with those under 65 years. However, this association varied by region: it was significant in Central and Southern Europe but not in other regions such as North America, Asia, or Northern Europe. This highlights the influence of cultural, legal, and healthcare system differences on end-of-life decision-making.
In terms of specific practices, the study found that withholding treatment was more common in older patients, while withdrawing treatment was more frequent in younger patients. For example, the proportion of withheld therapies, such as mechanical ventilation, vasopressors, and dialysis, was highest in the oldest age group, whereas withdrawal of these therapies occurred most often in patients under 65. Additionally, older patients experienced shorter times from ICU admission to the first limitation of therapy, suggesting earlier decision-making in this group.
Despite these differences in practice, the reasons for limiting LST were broadly consistent across age groups. The most common reason was unresponsiveness to maximal therapy, followed by neurologic conditions and chronic diseases. Patient age itself was rarely cited as the primary reason for limiting treatment, accounting for less than 4% of cases even in the oldest group. This indicates that while age correlates with treatment limitation, it is not typically used in isolation to justify decisions.
The study also explored decision-making processes. Physicians most frequently cited the patient’s best interests and good medical practice as the primary considerations guiding end-of-life decisions, with little variation across age groups. Patient autonomy played a greater role in older patients, who were more likely to have their treatment preferences documented or discussed. Indeed, the oldest group had the highest proportion of advanced directives and were more often involved in discussions about care limitations. Family discussions occurred in approximately 80% of cases across all groups.
ICU and hospital mortality were highest in the youngest group. This finding may reflect differences in disease severity and case selection. Younger patients were more likely to have severe acute conditions such as sepsis or haematological diseases, and fewer may have been excluded from ICU admission compared to severely ill elderly patients, who might instead receive ward-based end-of-life care.
The study identifies several possible explanations for age-related differences in LST practices. Older patients had higher rates of chronic conditions, particularly cardiovascular and neurologic diseases, which may influence prognostic assessments. They were also more likely to be mentally competent at the time of decision-making and to have communicated their preferences. Physicians may therefore feel more confident making earlier or more conservative decisions in this group. Additionally, treatments not initiated (withheld) do not later require withdrawal, which may partly explain the observed patterns.
Regional variation is a key finding. Differences in religion, cultural values, socioeconomic status, and legal frameworks likely contribute to how end-of-life care is approached. For example, family-centred decision-making and cultural attitudes towards ageing may shape practices differently across regions. The study also notes that countries with higher national income tend to have more frequent LST limitations.
Overall, the study demonstrates that older ICU patients, particularly those aged 80 and above, are more likely to experience limitations in life-sustaining therapy, with significant regional variation. However, these decisions are not primarily driven by age itself but by clinical factors such as prognosis and response to treatment. The findings emphasise that end-of-life care decisions are complex and multifactorial, with age acting as an associated, but not decisive, factor.
Source: Critical Care Medicine
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