Changes in End-of-Life Practices in European Intensive Care Units from 1999 to 2016
Sprung, Charles L.; Ricou, Bara; Hartog, Christiane S.; Maia, Paulo; Mentzelopoulos, Spyros D.; Weiss, Manfred; Levin, Phillip D.; Galarza, Laura; De La Guardia, Veronica; Schefold, Joerg C.; Baras, Mario; Joynt, Gavin M.; Bülow, Hans Henrik; Nakos, Georgios; Cerny, Vladimir; Marsch, Stephan; Girbes, Armand R.; Ingels, Catherine; Miskolci, Orsolya; Ledoux, Didier; Mullick, Sudakshina; Bocci, Maria G.; Gjedsted, Jakob; Estébanez, Belén; Nates, Joseph L.; Lesieur, Olivier; Sreedharan, Roshni; Giannini, Alberto M.; Fuciños, Lucía Cachafeiro; Danbury, Christopher M.; Michalsen, Andrej; Soliman, Ivo W.; Estella, Angel; Avidan, Alexander
(2019) JAMA - Journal of the American Medical Association, volume 322, issue 17, pp. 1692 - 1704
(Article)
Abstract
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
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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 13625 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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Keywords: General Medicine, Journal Article
ISSN: 0098-7484
Publisher: American Medical Association
Note: Funding Information: Greece: S. Zakynthinos (center coordinator), S. Mentzelopoulos, A. Kotanidou, S. Kokkoris, I. Pantazopoulos, G. Karlis, Evaggelsimos General Hospital, Athens; C. Mathas (center coordinator), Agia Olga Hospital of Nea Ionia, Athens; G Nakos (center coordinator), V. Koulouras, G. Papathanakos, University Hospital of Ioannina, Ioannina. Ireland: O. Miskolci (center coordinator), C. O'Loughlin, Mater Hospital, University College, Dublin. Israel: C.L. Sprung (center coordinator), A. Avidan, V. de la Guardia, A. Farran, V. Van Heerden, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem; M. Klein (center coordinator), E. Brotfain, Soroka Hospital, Beer-Sheva; P. Levin (center coordinator), N. Alon, Shaarei Zedek Medical Center, Jerusalem. Italy: A. Palo (center coordinator), S. Cortesi, S. Guarisco, Policlinico San Matteo, Pavia. The Netherlands: A. Girbes (center coordinator), E. Alberts, VU Hospital, Amsterdam. Portugal: P. Maia (center coordinator), Hospital Geral Santo Antonio, Porto; L. Bento (center coordinator), Hospital de S. Jose, Lisboa. Spain: J.M.G. Garcia (center coordinator), I. Saralegui, Hospital Gregorio Maradon, Madrid; B. Vidal Tegedor (center coordinator), L. Galarza, Hospital General Universitario de Castellon, Castellon. Switzerland: B. Ricou (center coordinator), G. Auzou, Hopital Cantonal Universitaire de Geneve, Geneva; S. Marsch (center coordinator), K. Tisljar, Kantosspital Basel, Basel. Turkey: F. Esen (center coordinator), P.E. Ozcan, O. Yenigun, University of Istanbul, Istanbul. United Kingdom: D. Brealey (center coordinator), R. Stoyanova, K. Tam, University College London, London. Conflict of Interest Disclosures: Dr Hartog reports receipt of grants to her institution from the German Federal Ministry of Education and Research (BMBF) via the Center for Sepsis Control and Care, German Innovations Funds/Federal Joint Committee, and the European Society of Intensive Care Medicine. Dr Schefold reports receipt of grants (all paid into departmental accounts) from Orion Pharma, Abbott Nutrition International, B. Braun Medical AG, CSEM AG, Edwards Lifesciences Services GmbH, Kenta Biotech, Maquet Critical Care AB, Omnicare Clinical Research AG, Nestle, Pierre Fabre Pharma AG, Pfizer, Bard Medica S.A., Abbott AG, Anandic Medical Systems, Pan Gas AG Healthcare, Bracco, Hamilton Medical AG, Fresenius Kabi, Getinge Group Maquet AG, Dräger AG, Teleflex Medical GmbH, Glaxo Smith Kline, Merck Sharp and Dohme AG, Eli Lilly and Company, Baxter, Astellas, Astra Zeneca, CSL Behring, Novartis, Covidien, and Nycomed outside the submitted work. No additional disclosures were reported. Funding/Support: This study was funded by the Walter F. and Alice Gorham Foundation. Role of the Funder/Sponsor: The Walter F. and Alice Gorham Foundation had no part in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Meeting Presentation: Presented at the European Society for Intensive Care Medicine’s annual congress; October 2, 2019; Berlin, Germany. Publisher Copyright: © 2019 American Medical Association. All rights reserved.
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