title: Reasons, considerations, difficulties and documentation of end-of-life decisions in European intensive care units: the ETHICUS Study.
abstract: OBJECTIVE
  To evaluate physicians' reasoning, considerations and possible difficulties in end-of-life decision-making for patients in European intensive care units (ICUs).
  
  
  METHODS
  A prospective observational study.
  
  
  METHODS
  Thirty-seven ICUs in 17 European countries.
  
  
  METHODS
  A total of 3,086 patients for whom an end-of-life decision was taken between January 1999 and June 2000. The dataset excludes patients who died after attempts at cardiopulmonary resuscitation and brain-dead patients.
  
  
  RESULTS
  Physicians indicated which of a pre-determined set of reasons for, considerations in, and difficulties with end-of-life decision-making was germane in each case as it arose. Overall, 2,134 (69%) of the decisions were documented in the medical record, with inter-regional differences in documentation practice. Primary reasons given by physicians for the decision mostly concerned the patient's medical condition (79%), especially unresponsive to therapy (46%), while chronic disease (12%), quality of life (4%), age (2%) and patient or family request (2%) were infrequent. Good medical practice (66%) and best interests (29%) were the commonest primary considerations reported, while resource allocation issues such as cost effectiveness (1%) and need for an ICU bed (0%) were uncommon. Living wills were considered in only 1% of cases. Physicians in central Europe reported no significant difficulty in 81% of cases, while in northern and southern regions there was no difficulty in 92-93% of cases.
  
  
  CONCLUSIONS
  European ICU physicians do not experience difficulties with end-of-life decisions in most cases. Allocation of limited resources is a minor consideration and autonomous choices by patient or family remain unusual. Inter-regional differences were found.
authors.affiliation: Hadassah Hebrew University Medical Center, General Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, P.O. Box 12000, 91120 Jerusalem, , Israel. sprung@cc.huji.ac.il
authors.forename: Charles L
authors.initials: CL
authors.lastname: Sprung
authors.forename: Thomas
authors.initials: T
authors.lastname: Woodcock
authors.forename: Peter
authors.initials: P
authors.lastname: Sjokvist
authors.forename: Bara
authors.initials: B
authors.lastname: Ricou
authors.forename: Hans-Henrik
authors.initials: HH
authors.lastname: Bulow
authors.forename: Anne
authors.initials: A
authors.lastname: Lippert
authors.forename: Paulo
authors.initials: P
authors.lastname: Maia
authors.forename: Simon
authors.initials: S
authors.lastname: Cohen
authors.forename: Mario
authors.initials: M
authors.lastname: Baras
authors.forename: Seppo
authors.initials: S
authors.lastname: Hovilehto
authors.forename: Didier
authors.initials: D
authors.lastname: Ledoux
authors.forename: Dermot
authors.initials: D
authors.lastname: Phelan
authors.forename: Elisabet
authors.initials: E
authors.lastname: Wennberg
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Schobersberger
mesh_terms: D001926:Brain Death; D016887:Cardiopulmonary Resuscitation / Q000941:ethics / Q000523:psychology; D003422:Critical Care / Q000941:ethics* / Q000379:methods / Q000523:psychology; D003657:Decision Making; D004282:Documentation; D005060:Europe; D005260:Female; D006801:Humans; D008297:Male; D010818:Practice Patterns, Physicians' / Q000941:ethics*; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D013727:Terminal Care / Q000941:ethics* / Q000379:methods / Q000523:psychology; D028761:Withholding Treatment