In intensive care units, death often occurs after a decision to limit life-sustaining interventions. But there are significant differences in these practices within and between different countries and regions. 

Over the past decade or so, there have been significant changes in European laws, recommendations, guidelines, and attitudes regarding end-of-life practices. These days, there is greater emphasis on shared decision making. Also, support for euthanasia and physician-assisted suicide has also increased in Europe. 
Findings from the Ethicus-1 study that was conducted between 1999-2000 in 37 European ICUS showed that the frequency of withholding life-prolonging therapies in Europe ranged from 16% to 70%, withdrawing life-prolonging therapies from 5% to 69%, active shortening of the dying process from 0% to 19%, and failed cardiopulmonary resuscitation from 5% to 48%. 

Ethicus-2 study was conducted to assess whether there has been a change in these practices from 1999-2000 to 2015-2016. The Ethicus-2 study included 22 European ICUs. Each ICU selected a continuous 6-month period and included any patients who died or had any limitation of life-sustaining therapy from September 2015 to October 2016. All patients were followed up until death or two months after their first treatment limitation decision. 

End-of-life outcomes were classified into five categories:
  • Withholding treatment which basically refers to a decision not to start or increase a life-sustaining intervention.
  • Withdrawing treatment that refers to a decision to stop a life-sustaining intervention already being given to a patient. 
  • Active shortening of the dying process that refers to an act that is performed with the intent of shortening the dying process. 
  • Failed CPR which means death despite ventilation and cardiac massage.
  • Brain death that refers to the cessation of cerebral function and meeting the criteria for brain death. 

13625 patients were included in this analysis during the 2015-2016 study period. Of these, 13.1% died or had limitations of life-prolonging therapies. 2807 patients were included in the 1999-2000 cohort. Patients in the 2015-2016 cohort were older than the 1999-2000 cohort. More treatment limitations occurred in the 2015-2016 cohort compared to the 1999-2000 cohort. More withholding of life-prolonging therapy, and more withdrawal of life-prolonging therapy was observed in the 2015-2016 cohort. There was less failed CPR, less brain death, and less shortening of the dying process in this cohort. 

Overall, these findings show that limitations in life-prolonging therapies occurred more frequently, and death without limitations in life-prolonging therapies occurred less frequently in European ICUs in 2015-2016 compared with 1999-2000. These findings thus indicate a shift in end-of-life practices in European ICUs. 

Source: JAMA
Image Credit: iStock 


Sprung CL et al. (2019) Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016. JAMA, doi:10.1001/jama.2019.14608

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ICU, intensive care unit, euthanasia, Physician-Assisted Suicide, end-of-life practices How have end-of-life practices in European ICUs changed from 1999-2000 to 2015-2016? A new review evaluates.