Skip to main content

Communication of end-of-life decisions in European intensive care units

Intensive Care Medicine volume 31, pages 1215–1221 (2005)Cite this article

Abstract

Objective

To examine end-of-life (EOL) practices in European ICUs: who makes these decisions, how they are made, communication of these decisions and questions on communication between the physicians, nurses, patients and families.

Design

Data collected prospectively on EOL decisions facilitated by a questionnaire including EOL decision categories, geographical regions, mental competency, information about patient wishes, and discussions with patients, families and health care professionals.

Setting

37 European ICUs in 17 countries

Patients

ICU physicians collected data on 4,248 patients.

Results

95% of patients lacked decision making capacity at the time of EOL decision and patient’s wishes were known in only 20% of cases. EOL decisions were discussed with the family in 68% of cases. Physicians reported having more information about patients’ wishes and discussions in the northern countries (31%, 88%) than central (16%, 70%) or southern (13%, 48%) countries. The family was more often told (88%) than asked (38%) about EOL decisions. Physicians’ reasons for not discussing EOL care with the family included the fact that the patient was unresponsive to therapy (39%), the family was unavailable (28%), and the family was thought not to understand (25%).

Conclusions

ICU patients typically lack decision-making capacity, and physicians know patients’ wishes in only 20% of EOL decisions. There were regional differences in discussions of EOL decisions with families and other physicians. In European ICUs there seems to be a need to improve communication

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

References

  1. Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, Ledoux D, Lippert A, Maia P, Phelan D, Schobersberger W, Wennberg E, Woodcock T (2003) End of life practices in European intensive care units—the Ethicus study. JAMA 290:790–797

    Article  PubMed  Google Scholar 

  2. Vincent JL (1999) Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med 27:1626–1633

    Article  PubMed  Google Scholar 

  3. Sjokvist P, Nilstun T, Svantesson M, Berggren L (1999) Withdrawal of life support—who should decide? Differences in attitudes among the general public, nurses and physicians. Intensive Care Med 25:949–954

    Article  PubMed  Google Scholar 

  4. Pijnenborg L, van der Maas PJ, Kardun JW, Glerum JJ, van Delden JJ, Looman CW (1995) Withdrawal or withholding of treatment at the end of life. Results of a nationwide study. Arch Intern Med 155:286–292

    Article  PubMed  Google Scholar 

  5. Deliens L, Mortier F, Bilsen J, Cosyns M, Vander Stichele R, Vanoverloop J, Koen I (2000) End-of Life decisions in medical practice in Flanders, Belgium: a nationwide survey. Lancet 356:1806–1811

    Article  PubMed  Google Scholar 

  6. Melltrop G, Nilstun T (1996) Decisions to forego life-sustaining treatment and the duty of documentation. Intensive Care Med 22:1015–1019

    PubMed  Google Scholar 

  7. Turner JS, Michell WL, Morgan CJ, Benatar SR (1996) Limitation of life support: frequency and practice in a London and Cape Town intensive care unit. Intensive Care Med 22:1020–1025

    PubMed  Google Scholar 

  8. Sjokvist P, Sundin PO, Berggren L (1998) Limiting life support. Experiences with a special protocol. Acta Anaesthesiol Scand 42:232–237

    PubMed  Google Scholar 

  9. Ferrand E, Robert R, Ingrand P, Lemaire F, French LG (2001) Withholding and withdrawal of life support in intensive care units in France: a prospective survey. French LATAREA Group. Lancet 357:9–14

    Article  PubMed  Google Scholar 

  10. Esteban A, Gordo F, Solsona F, 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 JM, Balerdi B (2001) Withdrawing and withholding life support in the intensive care unit: a Spanish prospective multi-centre observational study. Intensive Care Med 27:1744–1749

    Article  PubMed  Google Scholar 

  11. Smedira NG, Evans BH, Grais LS, Lo B, Cooke M, Schecter WP, Fink C, Epstein-Jaffe E, May C, Luce JM (1990) Withholding and withdrawal of life support from the critically ill. N Engl J Med 322:309−315

    PubMed  Google Scholar 

  12. Lee DKP, Swinburn AJ, Fedullo AJ, Wahl GW (1994) Withdrawing care. Experience in a medical intensive care unit. JAMA 271:1358–1361

    Article  PubMed  Google Scholar 

  13. Prendergast TJ, Luce JM (1997) Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med 155:15–20

    PubMed  Google Scholar 

  14. Cook DJ, Guyatt G, Rocker G, Sjokvist P, Weaver B, Dodek P, Marshall J, Leasa D, Levy M, Varon J, Fisher M, Cook R (2001) Cardiopulmonary resuscitation directives on admission to intensive care unit. An international observational study. Lancet 358:1941–1945

    Article  PubMed  Google Scholar 

  15. Layde PM, Beam CA, Broste SK, Connors AF Jr, Desbiens N, Lynn J, Phillips RS, Reading D, Teno J, Vidaillet H (1995) Surrogates’ predictions of seriously ill patients’ resuscitation preferences. Arch Fam Med 4:518–523

    Article  PubMed  Google Scholar 

  16. Uhlmann RF, Pearlman RA, Cain KC (1998) Physicians’ and spouses’ predictions of elderly patients’ resuscitation preferences. J Gerontol 43:M115–M121

    Google Scholar 

  17. Suhl J, Simons P, ReedyT, Garrick T (1994) Myth of substituted judgement. Surrogate decision making regarding life support is unreliable. Arch Intern Med 154:90–96

    Article  PubMed  Google Scholar 

  18. High DM (1998) All in the family: extended autonomy and expectations in the surrogate health care decision-making Gerontologist 28:46–51

  19. Cassell EJ, Leon AC, Kaufman SG (2001) Preliminary evidence of impaired thinking in sick patients. Ann Intern Med 134:1120–1123

    PubMed  Google Scholar 

  20. Pochard F, Azoulay E, Chevret C, Vinsonneau C, Grassin M, Lemaire F, Herve C, Schlemmer B, Zittoun R, Dhainaut J-F (2001) French Intensivists do not apply American recommendations regarding decisions to forgo life-sustaining therapy. Crit Care Med 29:1887–1892

    Article  PubMed  Google Scholar 

  21. Le Conte P, Baron D, Trewick D, Touze MD, Longo C, Vial I, Yaltin D, Potel G (2004) Withholding and withdrawing life support therapy in an emergency department: prospective study. Intensive Care Med 30:2216–2221

    Article  PubMed  Google Scholar 

  22. Tomlinson T, Brody H (1990) Futility and the ethics of resuscitation. JAMA 264:1276–1280

    Article  PubMed  Google Scholar 

  23. Heyland DK, Rocker GM, O’Callaghan CJ, Dodek PM, Cook DJ (2003) Dying in the ICU: perspectives of family members. Chest 124:392–397

    Article  PubMed  Google Scholar 

  24. Ferrand E, Lemaire F, Regnio B, Kuteisan K, Badet M, Asfar P, Jaber S, Chagon 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, end-of-life decisions. Am J Respir Crit Care Med 167:1310–1315

    Article  PubMed  Google Scholar 

  25. Daffurn K, Kerridge R, Hillman KM (1992) Active Management of the dying patient. Med J Aust 157:701–704

    PubMed  Google Scholar 

  26. Prendergast TJ, Claessens MT, Luce JM (1998) A National Survey of End of Life Care for critically ill patients. Am J Respir Crit Care Med 158:163–167

    Google Scholar 

Download references

Acknowledgements

The Ethicus Steering Committee: C. Sprung, S. Cohen, L. Epstein, D. Miranda, F. Lemaire, and G. Van Steendam. Participanting investigators and their affiliation are listed in Table 5.

Table 5 Participating investigators of the Ethicus study
Full size table

Author information

Affiliations

  1. Department of Medicine, University College London, London, UK

    Simon Cohen

  2. Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel

    Charles Sprung

  3. Department of Anesthesiology, Orebro University Hospital, Orebro, Sweden

    Peter Sjokvist

  4. Department of Anesthesiology, Herlev University Hospital, Herlev, Denmark

    Anne Lippert

  5. Hôpital Cantonal Universitaire de Geneve, Geneva, Switzerland

    Bara Ricou

  6. Hadassah School of Public Health, Hebrew University, Jerusalem, Israel

    Mario Baras

  7. Department of Anesthesiology, South Karelia Central Hospital, Lappeenranta, Finland

    Seppo Hovilehto

  8. Department of Intensive Care, Hospital Geral Santo Antonio, Porto, Portugal

    Paulo Maia

  9. Department of Intensive Care, Mater Hospital University College, Dublin, Ireland

    Dermot Phelan

  10. Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, Jena, Germany

    Konrad Reinhart

  11. Martin Luther University, Halle-Wittenberg, Halle, Germany

    Karl Werdan

  12. Department of Anesthesiology, University Hospital of Glostrup, Glostrup, Denmark

    Hans-Henrik Bulow

  13. Critical Care Directorate, Southampton University Hospitals NHS Trust, Southampton, UK

    Tom Woodcock

Authors
  1. Simon Cohen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Charles Sprung
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Peter Sjokvist
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Anne Lippert
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Bara Ricou
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mario Baras
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Seppo Hovilehto
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Paulo Maia
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Dermot Phelan
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Konrad Reinhart
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Karl Werdan
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Hans-Henrik Bulow
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Tom Woodcock
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Simon Cohen.

Additional information

P. Sjokvist died in December 2003

Funding was provided by the European Concerted Action project and by the European Commission (contract PL963733), the Chief Scientist’s Office of the Ministry of Health, Israel (grant no. 4226), the European Society of Intensive Care Medicine (ESICM) and by OFES Switzerland (Biomed, no. 980271)

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Cohen, S., Sprung, C., Sjokvist, P. et al. Communication of end-of-life decisions in European intensive care units. Intensive Care Med 31, 1215–1221 (2005). https://doi.org/10.1007/s00134-005-2742-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-005-2742-x

Keywords

  • End-of-life decisions
  • Europe
  • Intensive care units
  • Patient competency
  • Patient families
  • Regional differences