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

ETHICUS-2 Study Group, Alexander Avidan, Charles L. Sprung, Joerg C. Schefold, Bara Ricou, Christiane S. Hartog, Joseph L. Nates, Ulrich Jaschinski, Suzana M. Lobo, Gavin M. Joynt, Olivier Lesieur, Manfred Weiss, Massimo Antonelli, Hans Henrik Bülow, Maria G. Bocci, Annette Robertsen, Matthew H. Anstey, Belén Estébanez-Montiel, Alexandre Lautrette, Anastasiia GruberAngel Estella, Sudakshina Mullick, Roshni Sreedharan, Andrej Michalsen, Charles Feldman, Kai Tisljar, Martin Posch, Steven Ovu, Barbara Tamowicz, Alexandre Demoule, Freda DeKeyser Ganz, Hans Pargger, Alberto Noto, Philipp Metnitz, Laszlo Zubek, Veronica de la Guardia, Christopher M. Danbury, Orsolya Szűcs, Alessandro Protti, Mario Filipe, Steven Q. Simpson, Cameron Green, Alberto M. Giannini, Ivo W. Soliman, Claudio Piras, Eliana B. Caser, Manuel Hache-Marliere, Spyros D. Mentzelopoulos

Research output: Contribution to journalArticlepeer-review


Background: End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. Methods: In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. Findings: Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. Interpretation: Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. Funding: None.

Original languageEnglish
Pages (from-to)1101-1110
Number of pages10
JournalThe Lancet Respiratory Medicine
Issue number10
Publication statusPublished - Oct 2021

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine


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