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Global comparison of communication of end-of-life decisions in the intensive care unit

- Charles Feldman, Guy Richards

Are there regional differences in end-of-life communication practices in ICUs worldwide?


Prolonging life in the intensive care unit (ICU) is increasingly possible, so decisions to limit life-sustaining therapies are frequently made and communicated to patients and families/surrogates. Little is known about worldwide communication practices and influencing factors.

The gravity of these decisions and discussions, and the psychological stress that may ensue for all stakeholders, require a supportive environment with a collaborative multidisciplinary team. Importantly, most physician-family conferences appear to lack important elements of communication, such as those related to values and preferences.


This study is on how communication of end-of-life decisions was practiced worldwide from a multi-center, international, prospective, observational ICU study of consecutive patients who died or who had imitation of life-sustaining treatment and is an additional, standalone investigation, arising from the global Ethicus-2 study. It included the same patients from the Ethicus-2 study, recruited from 199 ICUs in 36 countries. Participating ICUs were grouped into eight defined geographical regions.

The ICU physician, or their designee, completed the form in each center, for each patient, following a decision to stop life-sustaining treatment, or death,

according to the instructions provided.


Of 87,951 consecutive patients admitted to 199 ICUs in 36 countries worldwide, over a mean duration of 5.9 months (range, 1-6 months), 12,850 died or had a limitation of life-sustaining therapy (14.6%).

Of the latter patients 9.3% were known to have an advance directive, 79.6% did not, and this information was not recorded in 11.1% (Table 1). The presence of an advance directive varied by region, with none reported in Africa and 49.3% reported in North America, but was generally very low in all regions outside North America (<13.1%).