Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016
Por:
Sprung CL, Ricou B, Hartog CS, Maia P, Mentzelopoulos SD, Weiss M, Levin PD, Galarza L, de la Guardia V, Schefold JC, Baras M, Joynt GM, Bülow HH, Nakos G, Cerny V, Marsch S, Girbes AR, Ingels C, Miskolci O, Ledoux D, Mullick S, Bocci MG, Gjedsted J, Estébanez B, Nates JL, Lesieur O, Sreedharan R, Giannini AM, Fuciños LC, Danbury CM, Michalsen A, Soliman IW, Estella A and Avidan A
Publicada:
5 nov 2019
Ahead of Print:
2 oct 2019
Categoría:
Medicine (miscellaneous)
Resumen:
Key PointsQuestionHave end-of-life practices in European intensive care units (ICUs) changed from 1999-2000 to 2015-2016? FindingsIn this prospective observational study of 1785 patients who had limitations in life-prolonging therapies or died in 22 European ICUs in 2015-2016, compared with data previously reported from the same ICUs in 1999-2000 (2807 patients), treatment limitations (withholding or withdrawing life-sustaining treatment or active shortening of the dying process) occurred significantly more frequently (89.7% vs 68.3%), whereas death without any limitations in life-prolonging therapies occurred significantly less frequently (10.3% vs 31.7%). MeaningThese findings suggest that end-of-life care practices in European ICUs changed from 1999-2000 to 2015-2016 with more limitations in life-prolonging therapies and fewer deaths without treatment limitations.
ImportanceEnd-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time. ObjectiveTo determine the changes in end-of-life practices in European ICUs after 16 years. Design, Setting, and ParticipantsEthicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision. ExposuresComparison between the 1999-2000 cohort vs 2015-2016 cohort. Main Outcomes and MeasuresEnd-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists. ResultsOf 13625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n=2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P<.001) and the proportion of female patients was similar (39.6% vs 38.7%; P=.58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P<.001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P<.001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P<.001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P<.001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P<.001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P<.001). Conclusions and RelevanceAmong patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.
This study compares changes in end-of-life practices (withholding or withdrawing of life-prolonging therapy, active shortening of the dying process, failed CPR, documentation of brain death) in 22 European ICUs between 1999-2000 and 2015-2016.
Filiaciones:
Sprung CL:
Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
Ricou B:
Department of Anesthesiology, Pharmacology, and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
Hartog CS:
Department of Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin and Klinik Bavaria, Kreischa, Germany
Maia P:
Intensive Care Department, Hospital S. Antonio, Centro Hospitalar do Porto, Porto, Portugal
Mentzelopoulos SD:
First Department of Intensive Care Medicine, University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
Weiss M:
Clinic of Anaesthesiology, University Hospital Medical School, Ulm, Germany
Levin PD:
General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
:
Intensive Care Unit, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
de la Guardia V:
Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
Schefold JC:
Inselspital, Department of Intensive Care Medicine, University of Bern, Switzerland
Baras M:
The Hebrew University-Hadassah School of Public Health, Jerusalem, Israel
Joynt GM:
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
Bülow HH:
Department of Anesthesiology and Intensive Care, Holbaek University Hospital, Zealand Region, Denmark
Nakos G:
Department of Intensive Care Medicine, University of Ioannina, Ioannina, Greece
Cerny V:
Department of Anesthesiology, Perioperative Medicine, and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Czech Republic
Marsch S:
Medical Intensive Care, University of Basel Hospital, Basel, Switzerland
Girbes AR:
Department of Intensive Care Medicine, VU Medical Center, Amsterdam, the Netherlands
Ingels C:
Intensive Care Medicine, University Hospitals K.U. Leuven, Leuven Belgium
Miskolci O:
Mater Misericordiae University Hospital, Intensive Care Unit, Dublin, Ireland
Ledoux D:
Department of Anesthesiology and Intensive Care Medicine, University of Liege, Liege, Belgium
Mullick S:
Critical Care Medicine,Tata Medical Center, Kolkata, India
Bocci MG:
Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
Gjedsted J:
Department of Anesthesia and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
Estébanez B:
Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
Nates JL:
Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston
Lesieur O:
Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
Sreedharan R:
Department of General Anesthesiology, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
Giannini AM:
Division of Pediatric Anesthesia and Intensive Care, ASST Spedali Civili, Brescia, Italy
Fuciños LC:
Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
Danbury CM:
Department of Intensive Care, Royal Berkshire Hospital, Berkshire, United Kingdom
Michalsen A:
Department of Anesthesiology and Critical Care, Medizin Campus Bodensee-Tettnang Hospital, Tettnang, Germany
Soliman IW:
Department of Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands
Estella A:
Intensive Care Department, University Hospital SAS of Jerez, Jerez de la Frontera, Spain
Avidan A:
Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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