Reasons, considerations, difficulties and documentation of end-of-life decisions in European intensive care units: the ETHICUS Study
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To evaluate physicians' reasoning, considerations and possible difficulties in end-of-life decision-making for patients in European intensive care units (ICUs).
A prospective observational study.
Thirty-seven ICUs in 17 European countries.
Patients and participants
A total of 3,086 patients for whom an end-of-life decision was taken between January 1999 and June 2000. The dataset excludes patients who died after attempts at cardiopulmonary resuscitation and brain-dead patients.
Measurements and results
Physicians indicated which of a pre-determined set of reasons for, considerations in, and difficulties with end-of-life decision-making was germane in each case as it arose. Overall, 2,134 (69%) of the decisions were documented in the medical record, with inter-regional differences in documentation practice. Primary reasons given by physicians for the decision mostly concerned the patient's medical condition (79%), especially unresponsive to therapy (46%), while chronic disease (12%), quality of life (4%), age (2%) and patient or family request (2%) were infrequent. Good medical practice (66%) and best interests (29%) were the commonest primary considerations reported, while resource allocation issues such as cost effectiveness (1%) and need for an ICU bed (0%) were uncommon. Living wills were considered in only 1% of cases. Physicians in central Europe reported no significant difficulty in 81% of cases, while in northern and southern regions there was no difficulty in 92–93% of cases.
European ICU physicians do not experience difficulties with end-of-life decisions in most cases. Allocation of limited resources is a minor consideration and autonomous choices by patient or family remain unusual. Inter-regional differences were found.
KeywordsWithholding treatment Physician's role Life-support care Intensive care units Europe Decision-making Reasons Difficulties Considerations
This study was funded by the European Concerted Action Project and by the European Commission (Contract PL 963733), the Chief Scientists' Office of the Ministry of Health, Israel (grant 4226), and the OFES Switzerland/Biomed (grant 980271). The study also received funding from the European Society of Intensive Care Medicine and the Walter F and Alice Gorham Foundation Inc.
- 4.Esteban A, Gordo F, Solsona JF, Alia I, Caballero J, Bouza C, Alcala-Zamora J, Cook DJ, Sanchez JM, Abizanda R, Miro G, Fernandez Del Cabo MJ, de Miguel E, Santos JA, Balerdi B (2001) Withdrawing and withholding life support in the intensive care unit: a Spanish prospective multi-centre observational study. Intensive Care Med 27:1744–1749PubMedCrossRefGoogle Scholar
- 16.Sprung CL, Maia P, Bulow HH, Ricou B, Armaganidis A, Baras M, Wennberg E, Reinhart K, Cohen SL, Fries DR, Nakos G, Thijs LG (2007) The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med 33:1732–1739PubMedCrossRefGoogle Scholar
- 18.Collins N, Phelan D, Marsh B, Sprung CL (2006) End-of-life care in the intensive care unit: the Irish Ethicus data. Crit Care Resuscitation 8:315–320Google Scholar
- 23.Cook D, Rocker G, Marshall J, Sjokvist P, Dodek P, Griffith L, Freitag A, Varon J, Bradley C, Levy M, Finfer S, Hamielec C, McMullin J, Weaver B, Walter S, Guyatt G (2003) Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 349:1123–1132PubMedCrossRefGoogle Scholar
- 37.Ferrand E, Lemaire F, Regnier B, Kuteifan K, Badet M, Asfar P, Jaber S, Chagnon JL, Renault A, Robert R, Pochard F, Herve C, Brun-Buisson C, Duvaldestin P (2003) Discrepancies between perceptions by physicians and nursing staff of intensive care unit end-of-life decisions. Am J Respir Crit Care Med 167:1310–1315PubMedCrossRefGoogle Scholar