Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study

Avidan, Alexander; Sprung, Charles L.; Schefold, Joerg C.; Ricou, Bara; Hartog, Christiane S.; Nates, Joseph L.; Jaschinski, Ulrich; Lobo, Suzana M.; Joynt, Gavin M.; Lesieur, Olivier; Weiß, Manfred; Antonelli, Massimo; Bülow, Hans-Henrik; Bocci, Maria Grazia; Robertsen, Annette; Anstey, Matthew H; Estebanez-Montiel, Belén; Lautrette, Alexandre; Gruber, Anastasiia; Estella, Ángel; Mullick, Sudakshina; Sreedharan, Roshni; Michalsen, Andrej; Feldman, Charles; Tisljar, Kai; Posch, Martin; Ovu, Steven; Tamowicz, Barbara; Demoule, Alexandre; Ganz, Freda DeKeyser; Pargger, Hans; Noto, Alberto; Metnitz, Philipp; Zubek, László; Guardia, Veronica de la; Danbury, Chris; Szűcs, Orsolya; Protti, Alessandro; Filipe, Mario; Simpson, Steven Q.; Green, Cameron; Giannini, Alberto; Soliman, Ivo W.; Piras, Cláudio; Caser, Eliana Bernadete; Hache-Marliere, Manuel; Mentzelopoulos, Spyros D.

doi:10.1016/s2213-2600(21)00261-7

Cited by 76 publications

(73 citation statements)

References 32 publications

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“…The difference was even more pronounced in the matched pair analysis with almost twice as many decisions to withhold treatment in COVID compared with non-COVID patients. The results in the non-COVID patients agree with our previous study [ 28 ] and with other recent international studies [ 29 , 30 ] and are in line with a documented relation between treatment limitations and pressure on intensive care units in elderly patients [ 27 ]. We provide additional information about the timing of LLST.…”

Section: Discussionsupporting

confidence: 93%

Increased 30-day mortality in very old ICU patients with COVID-19 compared to patients with respiratory failure without COVID-19

Guidet

Jung²,

Flaatten³

et al. 2022

Intensive Care Med

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Purpose The number of patients ≥ 80 years admitted into critical care is increasing. Coronavirus disease 2019 (COVID-19) added another challenge for clinical decisions for both admission and limitation of life-sustaining treatments (LLST). We aimed to compare the characteristics and mortality of very old critically ill patients with or without COVID-19 with a focus on LLST. Methods Patients 80 years or older with acute respiratory failure were recruited from the VIP2 and COVIP studies. Baseline patient characteristics, interventions in intensive care unit (ICU) and outcomes (30-day survival) were recorded. COVID patients were matched to non-COVID patients based on the following factors: age (± 2 years), Sequential Organ Failure Assessment (SOFA) score (± 2 points), clinical frailty scale (± 1 point), gender and region on a 1:2 ratio. Specific ICU procedures and LLST were compared between the cohorts by means of cumulative incidence curves taking into account the competing risk of discharge and death. Results 693 COVID patients were compared to 1393 non-COVID patients. COVID patients were younger, less frail, less severely ill with lower SOFA score, but were treated more often with invasive mechanical ventilation (MV) and had a lower 30-day survival. 404 COVID patients could be matched to 666 non-COVID patients. For COVID patients, withholding and withdrawing of LST were more frequent than for non-COVID and the 30-day survival was almost half compared to non-COVID patients. Conclusion Very old COVID patients have a different trajectory than non-COVID patients. Whether this finding is due to a decision policy with more active treatment limitation or to an inherent higher risk of death due to COVID-19 is unclear. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06642-z.

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Section: Discussionsupporting

confidence: 93%

Increased 30-day mortality in very old ICU patients with COVID-19 compared to patients with respiratory failure without COVID-19

Guidet

Jung²,

Flaatten³

et al. 2022

Intensive Care Med

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“…Ethicus-2, a more recent prospective, multinational, observational study shows that the limitation of life-sustaining treatment (LST) occurs in about 12% of patients admitted to ICUs. This study confirms that treatment limitations are much more common in North America, Australia/New Zealand and Northern Europe than in Africa, Latin America and Southern Europe, and withholding LST is more common than withdrawing [ 7 ].…”

Section: Introductionsupporting

confidence: 82%

“…This may be caused by the discrepancy between the attitudes created by the reality ICU medical professionals witness on a daily basis and what is allowed by the law. Croatia is a mainly catholic country [ 26 ] and paternalistic and conservative attitudes are expected considering geographical location in Southern Europe, as found by previous studies [ 3 – 7 ].…”

Section: Discussionmentioning

confidence: 88%

“…More recent research conducted in the Netherlands, Switzerland, Denmark, Sweden, Belgium and Italy showed that 23–51% of patients died after a decision to limit LST has been made [ 28 ], while Ethicus-2 study showed that such a decision is made in as much as 12% of patients admitted to ICU and in almost 81% of the study population, which included patients who died in the ICU. It also showed that withholding of LST occurred in 44% and withdrawing of LST occurred in 36% of the study population [ 7 ]. A study conducted in the ICUs in the city of Milan, Italy, showed that 73% of physicians indicated that DNACPR orders were used in their ICU [ 29 ].…”

Section: Discussionmentioning

confidence: 99%

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Experiences and attitudes of medical professionals on treatment of end-of-life patients in intensive care units in the Republic of Croatia: a cross-sectional study

et al. 2022

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Background Decisions about limitations of life sustaining treatments (LST) are made for end-of-life patients in intensive care units (ICUs). The aim of this research was to explore the professional and ethical attitudes and experiences of medical professionals on treatment of end-of-life patients in ICUs in the Republic of Croatia. Methods A cross-sectional study was conducted among physicians and nurses working in surgical, medical, neurological, and multidisciplinary ICUs in the total of 9 hospitals throughout Croatia using a questionnaire with closed and open type questions. Exploratory factor analysis was conducted to reduce data to a smaller set of summary variables. Mann–Whitney U test was used to analyse the differences between two groups and Kruskal–Wallis tests were used to analyse the differences between more than two groups. Results Less than third of participants (29.2%) stated they were included in the decision-making process, and physicians are much more included than nurses (p < 0.001). Sixty two percent of participants stated that the decision-making process took place between physicians. Eighteen percent of participants stated that ‘do-not-attempt cardiopulmonary resuscitations’ orders were frequently made in their ICUs. A decision to withdraw inotropes and antibiotics was frequently made as stated by 22.4% and 19.9% of participants, respectively. Withholding/withdrawing of LST were ethically acceptable to 64.2% of participants. Thirty seven percent of participants thought there was a significant difference between withholding and withdrawing LST from an ethical standpoint. Seventy-nine percent of participants stated that a verbal or written decision made by a capable patient should be respected. Physicians were more inclined to respect patient’s wishes then nurses with high school education (p = 0.038). Nurses were more included in the decision-making process in neurological than in surgical, medical, or multidisciplinary ICUs (p < 0.001, p = 0.005, p = 0.023 respectively). Male participants in comparison to female (p = 0.002), and physicians in comparison to nurses with high school and college education (p < 0.001) displayed more liberal attitudes about LST limitation. Conclusions DNACPR orders are not commonly made in Croatian ICUs, even though limitations of LST were found ethically acceptable by most of the participants. Attitudes of paternalistic and conservative nature were expected considering Croatia’s geographical location in Southern Europe.

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“…This could be considered to be discriminatory and the question whether age in itself should be considered acceptable as a selection criterion remains unsolved. What is considered ethically acceptable or not differs between societies as is illustrated by the huge differences in, for example, end-of-life care or withholding of treatments while being admitted to the ICU [ 3 ]. Our analysis sought to investigate the relationship between the decision to limit therapy and the 7-day incidence of COVID-19 patients as a surrogate of ICU pressure in elderly patients.…”

mentioning

confidence: 99%

The relationship between treatment limitations and pressure on intensive care units in elderly patients

et al. 2021

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Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study

Cited by 76 publications

References 32 publications

Increased 30-day mortality in very old ICU patients with COVID-19 compared to patients with respiratory failure without COVID-19

Increased 30-day mortality in very old ICU patients with COVID-19 compared to patients with respiratory failure without COVID-19

Experiences and attitudes of medical professionals on treatment of end-of-life patients in intensive care units in the Republic of Croatia: a cross-sectional study

The relationship between treatment limitations and pressure on intensive care units in elderly patients

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