HILE THE PRINCIPLE THAT dying patients should be treated with respect and compassionisbroadlyaccepted among health care professionals, medical practices for end-of-life care differ around the world. In the United States, medicine has moved from a paternalistic model to one that promotes autonomy and self-determination. 1,2 Patient expectations and preferences now help shape end-of-life practices, limiting the use of technologies that may prolong dying rather than facilitate recovery. 1,2 In Europe, patient-physician relationships are still somewhat paternalistic. 3-5 Different cultures and countries deal in diverse ways with the ethical dilemmas arising as a consequence of the wider availability of life-sustaining therapies. 3,4,6 Some have not adopted the Western emphasis on patient autonomy or methods of terminating life support. 3,4,6 In the past, patients died in intensive care units (ICUs) despite ongoing aggressive therapy. 7 Theoretical discussions 7 and attitudes of critical care Author Affiliations and the members of the Ethicus Study Group are listed at the end of this article.

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.

IntroductionKnowledge of the association of hemodynamics with progression of septic acute kidney injury (AKI) is limited. However, some recent data suggest that mean arterial pressure (MAP) exceeding current guidelines (60–65 mmHg) may be needed to prevent AKI. We hypothesized that higher MAP during the first 24 hours in the intensive care unit (ICU), would be associated with a lower risk of progression of AKI in patients with severe sepsis.MethodsWe identified 423 patients with severe sepsis and electronically recorded continuous hemodynamic data in the prospective observational FINNAKI study. The primary endpoint was progression of AKI within the first 5 days of ICU admission defined as new onset or worsening of AKI by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. We evaluated the association of hemodynamic variables with this endpoint. We included 53724 10-minute medians of MAP in the analysis. We analysed the ability of time-adjusted MAP to predict progression of AKI by receiver operating characteristic (ROC) analysis.ResultsOf 423 patients, 153 (36.2%) had progression of AKI. Patients with progression of AKI had significantly lower time-adjusted MAP, 74.4 mmHg [68.3-80.8], than those without progression, 78.6 mmHg [72.9-85.4], P < 0.001. A cut-off value of 73 mmHg for time-adjusted MAP best predicted the progression of AKI. Chronic kidney disease, higher lactate, higher dose of furosemide, use of dobutamine and time-adjusted MAP below 73 mmHg were independent predictors of progression of AKI.ConclusionsThe findings of this large prospective multicenter observational study suggest that hypotensive episodes (MAP under 73 mmHg) are associated with progression of AKI in critically ill patients with severe sepsis.

More than half of the patients with severe sepsis had AKI according to the KDIGO classification, and AKI stage 3 was independently associated with 90-day mortality.

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.