Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016,JAMA

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Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016
JAMA ( IF 63.1 ) Pub Date : 2019-11-05 , DOI: 10.1001/jama.2019.14608
Charles L Sprung ₁ , Bara Ricou ₂ , Christiane S Hartog ₃ , Paulo Maia ₄ , Spyros D Mentzelopoulos ₅ , Manfred Weiss ₆ , Phillip D Levin ₇ , Laura Galarza ₈ , Veronica de la Guardia ₁ , Joerg C Schefold ₉ , Mario Baras ₁₀ , Gavin M Joynt ₁₁ , Hans-Henrik Bülow ₁₂ , Georgios Nakos ₁₃ , Vladimir Cerny ₁₄ , Stephan Marsch ₁₅ , Armand R Girbes ₁₆ , Catherine Ingels ₁₇ , Orsolya Miskolci ₁₈ , Didier Ledoux ₁₉ , Sudakshina Mullick ₂₀ , Maria G Bocci ₂₁ , Jakob Gjedsted ₂₂ , Belén Estébanez ₂₃ , Joseph L Nates ₂₄ , Olivier Lesieur ₂₅ , Roshni Sreedharan ₂₆ , Alberto M Giannini ₂₇ , Lucía Cachafeiro Fuciños ₂₃ , Christopher M Danbury ₂₈ , Andrej Michalsen ₂₉ , Ivo W Soliman ₃₀ , Angel Estella ₃₁ , Alexander Avidan ₁

Affiliation

Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel.
Department of Anesthesiology, Pharmacology, and Intensive Care, University Hospital of Geneva, Geneva, Switzerland.
Department of Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin and Klinik Bavaria, Kreischa, Germany.
Intensive Care Department, Hospital S. Antonio, Centro Hospitalar do Porto, Porto, Portugal.
First Department of Intensive Care Medicine, University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece.
Clinic of Anaesthesiology, University Hospital Medical School, Ulm, Germany.
General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel.
Intensive Care Unit, Hospital General Universitario de Castellón, Castellón de la Plana, Spain.
Inselspital, Department of Intensive Care Medicine, University of Bern, Switzerland.
The Hebrew University-Hadassah School of Public Health, Jerusalem, Israel.
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China.
Department of Anesthesiology and Intensive Care, Holbaek University Hospital, Zealand Region, Denmark.
Department of Intensive Care Medicine, University of Ioannina, Ioannina, Greece.
Department of Anesthesiology, Perioperative Medicine, and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Czech Republic.
Medical Intensive Care, University of Basel Hospital, Basel, Switzerland.
Department of Intensive Care Medicine, VU Medical Center, Amsterdam, the Netherlands.
Intensive Care Medicine, University Hospitals K.U. Leuven, Leuven Belgium.
Mater Misericordiae University Hospital, Intensive Care Unit, Dublin, Ireland.
Department of Anesthesiology and Intensive Care Medicine, University of Liege, Liege, Belgium.
Critical Care Medicine,Tata Medical Center, Kolkata, India.
Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
Department of Anesthesia and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark.
Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain.
Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston.
Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France.
Department of General Anesthesiology, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio.
Division of Pediatric Anesthesia and Intensive Care, ASST Spedali Civili, Brescia, Italy.
Department of Intensive Care, Royal Berkshire Hospital, Berkshire, United Kingdom.
Department of Anesthesiology and Critical Care, Medizin Campus Bodensee-Tettnang Hospital, Tettnang, Germany.
Department of Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands.
Intensive Care Department, University Hospital SAS of Jerez, Jerez de la Frontera, Spain.

Importance End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time. Objective To determine the changes in end-of-life practices in European ICUs after 16 years. Design, Setting, and Participants Ethicus-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. Exposures Comparison between the 1999-2000 cohort vs 2015-2016 cohort. Main Outcomes and Measures End-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. Results Of 13 625 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 Relevance Among 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.

中文翻译：

1999 年至 2016 年欧洲重症监护病房临终实践的变化

重要性世界各地的重症监护病房 (ICU) 每天都会做出临终决定，这些做法可能会随着时间而改变。目的确定 16 年后欧洲 ICU 临终实践的变化。设计、设置和参与者 Ethicus-2 是一项前瞻性观察研究，对 22 个欧洲 ICU 先前纳入 Ethicus-1 研究（1999-2000）。在每个 ICU 的自选连续 6 个月期间，包括 2015 年 9 月至 2016 年 10 月期间死亡或生命维持治疗有任何限制的连续患者。对患者进行随访直至死亡或第一次治疗限制决定后 2 个月。1999-2000 年队列与 2015-2016 年队列之间的暴露比较。主要结果和措施临终结果分为 5 个相互排斥的类别（停止延长生命治疗、停止延长生命治疗、主动缩短死亡过程、心肺复苏术 [CPR] 失败、脑死亡）。主要结果是患者是否接受任何治疗限制（拒绝或停止延长生命的治疗或缩短死亡过程）。结果由高级重症监护医师确定。结果 2015-2016 年研究期间，13625 名入住 ICU 的患者中，1785 名（13.1%）死亡或延长生命的治疗受到限制，并被纳入研究。与 1999-2000 年队列中的患者（n = 2807）相比，2015-2016 年队列中的患者年龄明显更大（中位年龄，70 岁 [四分位距 {IQR}，59-79] 与 67 岁 [IQR，54-75]；P < .001）和女性患者的比例相似（39.6% vs 38.7%；P = .58）。与 1999-2000 年队列相比，2015-2016 年队列出现了更多的治疗限制（1601 [89.7%] vs 1918 [68.3%]；差异为 21.4% [95% CI，19.2% 至 23.6%]；P < . 001)，延长生命的治疗停止更多（892 [50.0%] vs 1143 [40.7%]；差异，9.3% [95% CI，6.4% 至 12.3%]；P < .001），更多的生命退出- 延长治疗时间（692 [38.8%] vs 695 [24.8%]；差异，14.0% [95% CI，11.2% 至 16.8%]；P < .001），CPR 失败率更低（110 [6.2%] vs 628 [ 22.4%]；差异，-16.2% [95% CI，-18.1% 至 -14.3%]；P < .001)，更少的脑死亡（74 [4.1%] vs 261 [9.3%]；差异，-5.2% [95% CI，-6.6% 至 -3.8%]；P < . 001）和较少主动缩短死亡过程（17 [1.0%] vs 80 [2.9%]；差异，-1.9% [95% CI，-2.7% 至 -1.1%]；P < .001）。结论和相关性在 2015-2016 年在 22 个欧洲 ICU 中出现治疗限制或死亡的患者中，与 1999-2000 年同一 ICU 报告的数据相比，延长生命治疗的限制发生率明显更高，死亡无生命限制延长治疗的发生频率明显降低。这些发现表明欧洲 ICU 的临终实践发生了转变，但该研究的局限性在于它排除了在没有治疗限制的情况下在 ICU 住院中幸存下来的患者。结论和相关性在 2015-2016 年在 22 个欧洲 ICU 中治疗受限或死亡的患者中，与 1999-2000 年同一 ICU 报告的数据相比，延长生命治疗受限的发生率明显更高，死亡无生命受限延长治疗的发生频率明显降低。这些发现表明欧洲 ICU 的临终实践发生了转变，但该研究的局限性在于它排除了在没有治疗限制的情况下在 ICU 住院中幸存下来的患者。结论和相关性在 2015-2016 年在 22 个欧洲 ICU 中治疗受限或死亡的患者中，与 1999-2000 年同一 ICU 报告的数据相比，延长生命治疗受限的发生率明显更高，死亡无生命受限延长治疗的发生频率明显降低。这些发现表明欧洲 ICU 的临终实践发生了转变，但该研究的局限性在于它排除了在没有治疗限制的情况下在 ICU 住院中幸存下来的患者。

更新日期：2019-11-05

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