title: Forgoing life sustaining treatments: differences and similarities between North America and Europe.
abstract: BACKGROUND
  As evidence exist that severe neurological damage or prolonged death after inappropriate CPR could occur, restraints and indications for CPR were perceived as necessary. The objective of this review is to examine policies and attitudes towards end-of-life decisions in Europe and North America and to outline differences and similarities.
  
  
  METHODS
  A bibliographic database search from 1990 to 2006 was performed using the following terms: do-not-resuscitate orders, end-of-life decisions, withholding/withdrawal of life-sustaining treatments, medical futility and advanced directives. Eighty-eight articles, out of 305 examined, were analyzed and their data systematically reported and compared where possible. They consisted of studies, questionnaires and surveys answering the following questions: percentage of deaths of critical patients preceded by do-not-resuscitate orders, factors affecting the decision for do-not-resuscitate orders, people involved in this decision (patient, surrogates and medical staff) and how it was performed.
  
  
  RESULTS
  There is an evident gap between the North American use of standard and formal procedures compared with Europe. Second, they diverge in the role acknowledged to surrogates in the decisional process, as in Europe, restraints and reserves to accept surrogates as decision makers seem still strong and a paternalistic approach at the end-of-life is still present.
  
  
  CONCLUSIONS
  Incidentally, despite the predictable differences between Europe and North America, concerns do exist about the actual extent of autonomy wished by patients and surrogates. It is important to highlight these findings, as the paternalistic attitude, too often negatively depicted, could be, according to the best medical practice, justified and more welcomed in some instances.
authors.affiliation: Unit of Anaesthesiology, Intensive Care and Pain Therapy, Institute for Cancer Research and Treatment (IRCC), Candiolo (Torino), Italy. nmoselli@mauriziano.it
authors.forename: N M
authors.initials: NM
authors.lastname: Moselli
authors.forename: F
authors.initials: F
authors.lastname: Debernardi
authors.forename: F
authors.initials: F
authors.lastname: Piovano
mesh_terms: D016887:Cardiopulmonary Resuscitation / Q000706:statistics & numerical data; D002986:Clinical Trials as Topic; D003431:Cross-Cultural Comparison; D003657:Decision Making; D005060:Europe; D006801:Humans; D009656:North America; D010358:Patient Participation; D016414:Resuscitation Orders / Q000523:psychology; D013727:Terminal Care / Q000706:statistics & numerical data*; D028761:Withholding Treatment / Q000706:statistics & numerical data*