以色列耶路撒冷希伯来大学Alexander Avidan研究小组的一项最新研究，分析了从1999年到2016年，欧洲重症监护病房的临终行为的变化。这一研究成果发表在2019年11月5日出版的国际学术期刊《美国医学会杂志》上。

据悉，世界各地的重症监护病房（ICU）每天都会做出临终决定，但这些决定可能会随着时间的推移而改变。

1999-2000年，研究组曾在欧洲的22个ICU进行了一项前瞻性的观察研究。2015年9月至2016年10月，研究组再次对这22个ICU连续6个月期间的死亡或限制生命维持治疗的患者进行分析。每位患者均随访至死亡或限制治疗后2个月。

2015-2016年间，ICU中1785名死亡或限制延长生命治疗的患者被纳入研究，中位年龄为70岁，显著大于1999-2000年组中的2807名患者（67岁），但两组患者的性别比例相差不大。

Title: Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

Author: Charles L. Sprung, Bara Ricou, Christiane S. Hartog, Paulo Maia, Spyros D. Mentzelopoulos, Manfred Weiss, Phillip D. Levin, Laura Galarza, Veronica de la Guardia, Joerg C. Schefold, Mario Baras, Gavin M. Joynt, Hans-Henrik Bülow, Georgios Nakos, Vladimir Cerny, Stephan Marsch, Armand R. Girbes, Catherine Ingels, Orsolya Miskolci, Didier Ledoux, Sudakshina Mullick, Maria G. Bocci, Jakob Gjedsted, Belén Estébanez, Joseph L. Nates, Olivier Lesieur, Roshni Sreedharan, Alberto M. Giannini, Lucía Cachafeiro Fucios, Christopher M. Danbury, Andrej Michalsen, Ivo W. Soliman, Angel Estella, Alexander Avidan

Issue&Volume: 2019/11/05

Abstract: 

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.

DOI: 10.1001/jama.2019.14608

Source: https://jamanetwork.com/journals/jama/article-abstract/2752581