Intensive Care Medicine

, Volume 34, Issue 2, pp 271–277 | Cite as

Reasons, considerations, difficulties and documentation of end-of-life decisions in European intensive care units: the ETHICUS Study

  • Charles L. Sprung
  • Thomas Woodcock
  • Peter Sjokvist
  • Bara Ricou
  • Hans-Henrik Bulow
  • Anne Lippert
  • Paulo Maia
  • Simon Cohen
  • Mario Baras
  • Seppo Hovilehto
  • Didier Ledoux
  • Dermot Phelan
  • Elisabet Wennberg
  • Wolfgang Schobersberger



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.


Withholding 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.


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Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Charles L. Sprung
    • 1
  • Thomas Woodcock
    • 2
  • Peter Sjokvist
    • 3
  • Bara Ricou
    • 4
  • Hans-Henrik Bulow
    • 5
  • Anne Lippert
    • 6
  • Paulo Maia
    • 7
  • Simon Cohen
    • 8
  • Mario Baras
    • 9
  • Seppo Hovilehto
    • 10
  • Didier Ledoux
    • 11
  • Dermot Phelan
    • 12
  • Elisabet Wennberg
    • 13
  • Wolfgang Schobersberger
    • 14
  1. 1.General Intensive Care Unit, Department of Anesthesiology and Critical Care MedicineHadassah Hebrew University Medical CenterJerusalem, Israel
  2. 2.Critical Care DirectorateSouthampton University Hospitals NHS TrustSouthamptonUK
  3. 3.Department of AnesthesiologyOrebro and Huddinge University HospitalStockholmSweden
  4. 4.Department of AnesthesiologyHopital Cantonal Universitaire de GeneveGenevaSwitzerland
  5. 5.Department of AnesthesiologyUniversity Hospital of GlostrupGlostrupDenmark
  6. 6.Department of AnesthesiologyHerlev University HospitalHerlevDenmark
  7. 7.Department of Intensive CareHospital Geral Santo AntonioPortoPortugal
  8. 8.Department of MedicineUniversity College of LondonLondonUK
  9. 9.The Hebrew University – Hadassah School of Public HealthHadassah Hebrew University Medical CenterJerusalemIsrael
  10. 10.Department of AnesthesiologySouth Karelia Central HospitalLappeenrantaFinland
  11. 11.Department of Anesthesiology and Intensive Care MedicineUniversity of LiegeLiegeBelgium
  12. 12.Department of Intensive CareMater Hospital, University CollegeDublinIreland
  13. 13.Department of Anesthesia and Intensive CareSahlgrenska University HospitalGothenburgSweden
  14. 14.Division for General and Surgical Intensive Care MedicineUniversity Hospital InnsbruckInnsbruckAustria

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