While the adoption of practice guidelines is standardizing many aspects
of patient care, ethical dilemmas are occurring because of forgoing life-sustaining
therapies in intensive care and are dealt with in diverse ways between different
countries and cultures.
To determine the frequency and types of actual end-of-life practices
in European intensive care units (ICUs) and to analyze the similarities and
Design and Setting
A prospective, observational study of European ICUs.
Consecutive patients who died or had any limitation of therapy.
Prospectively defined end-of-life practices in 37 ICUs in 17 European
countries were studied from January 1, 1999, to June 30, 2000.
Main Outcome Measures
Comparison and analysis of the frequencies and patterns of end-of-life
care by geographic regions and different patients and professionals.
Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died
or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%)
had limitations of treatments (10% of admissions). Substantial intercountry
variability was found in the limitations and the manner of dying: unsuccessful
cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range,
0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy
in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range,
0%-19%). Shortening of the dying process was reported in 7 countries. Doses
of opioids and benzodiazepines reported for shortening of the dying process
were in the same range as those used for symptom relief in previous studies.
Limitation of therapy vs continuation of life-sustaining therapy was associated
with patient age, acute and chronic diagnoses, number of days in ICU, region,
and religion (P<.001).
The limiting of life-sustaining treatment in European ICUs is common
and variable. Limitations were associated with patient age, diagnoses, ICU
stay, and geographic and religious factors. Although shortening of the dying
process is rare, clarity between withdrawing therapies and shortening of the
dying process and between therapies intended to relieve pain and suffering
and those intended to shorten the dying process may be lacking.