• Charles Feldman, Charles L Sprung, Spyros D Mentzelopoulos, Anne Pohrt, Christiane S Hartog, Christopher Danbury, Manfred Weiss, Alexander Avidan, Angel Estella, Gavin M Joynt, Alexandre Lautrette, Edoardo Geat, Gábor Élő, Eldar Søreide, Olivier Lesieur, Maria G Bocci, Sudakshina Mullick, Annette Robertsen, Roshni Sreedharan, Hans-Henrik Bülow, Paulo A Maia, Mariá Cruz Martin-Delgado, Joseph F Cosgrove, Nikki Blackwell, Silvia Perez-Protto, Guy A Richards, and Ethicus-2 Study Group.
• Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. Electronic address: charles.feldman@wits.ac.za.
• Chest. 2022 Nov 1; 162 (5): 107410851074-1085.

BackgroundProlonging life in the ICU increasingly is possible, so decisions to limit life-sustaining therapies frequently are made and communicated to patients and families or surrogates. Little is known about worldwide communication practices and influencing factors.Research QuestionAre there regional differences in end-of-life communication practices in ICUs worldwide?Study Design And MethodsThis analysis of data from a prospective, international study specifically addressed end-of-life communications in consecutive patients who died or had limitation of life-sustaining therapy over 6 months in 199 ICUs in 36 countries, grouped regionally. End-of-life decisions were recorded for each patient and ethical practice was assessed retrospectively for each ICU using a 12-point questionnaire developed previously.ResultsOf 87,951 patients admitted, 12,850 died or experienced a limitation of therapy (14.6%). Of these, 1,199 patients (9.3%) were known to have an advance directive, and wishes were elicited from 6,456 patients (50.2%). Limitations of life-sustaining therapy were implemented for 10,401 patients (80.9%), 1,970 (19.1%) of whom had mental capacity at the time, and were discussed with 1,507 patients (14.5%) and 8,461 families (81.3%). Where no discussions with patients occurred (n = 8,710), this primarily was because of a lack of mental capacity in 8,114 patients (93.2%), and where none occurred with families (n = 1,622), this primarily was because of unavailability (n = 720 [44.4%]). Regional variation was noted for all end points. In generalized estimating equation (GEE) analyses, the odds for discussions with the patient or family increased by 30% (OR, 1.30; 95% CI, 1.18-1.44; P < .001) for every one-point increase in the Ethical Practice Score and by 92% (OR, 1.92; 95% CI, 1.28-2.89; P = .002) in the presence of an advance directive.InterpretationEnd-of-life communication with patients and families or surrogates varies markedly in different global regions. GEE analysis supports the hypothesis that communication may increase with ethical practice and an advance directive. Greater effort is needed to align treatment with patients' wishes.Copyright © 2022 American College of Chest Physicians. All rights reserved.

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