ORIGINAL INVESTIGATION
International Differences in End-of-Life Attitudes
in the Intensive Care Unit
Results of a Survey
Arino Yaguchi, MD; Robert D. Truog, MD; J. Randall Curtis, MD; John M. Luce, MD;
Mitchell M. Levy, MD; Christian Mélot, MD; Jean-Louis Vincent, MD, PhD
Background: Important international differences ex-
ist in attitudes toward end-of-life issues in the intensive
care unit.
Methods: A simple questionnaire survey was sent by
e-mail to participants at an international meeting on intensive care medicine. Respondents were asked to choose
1 of 3 to 5 possible answers for each of 4 questions related to the treatment of a hypothetical patient in a vegetative state due to anoxic encephalopathy after cardiac
arrest with no family and no advance directives.
Results: From 3494 valid addresses, 1961 complete ques-
tionnaires (56%) were received from 21 countries. Sixtytwo percent of physicians from Northern and Central Europe said they involved nurses in end-of-life discussions
compared with only 32% of physicians in Southern Europe, 38% in Brazil, 39% in Japan, and 29% in the United
States (P⬍.001 for all comparisons). Written do-notresuscitate orders were preferred in Northern and Cen-
Author Affiliations:
Department of Intensive Care
Medicine, Erasme Hospital,
Free University of Brussels,
Brussels, Belgium (Drs Yaguchi,
Mélot, and Vincent);
Department of Anesthesia and
Medical Ethics, Harvard
Medical School, Children’s
Hospital, Boston, Mass
(Dr Truog); Division of
Pulmonary and Critical Care
Medicine, University of
Washington, Harborview
Medical Center, Seattle
(Dr Curtis); Department of
Medicine and Anesthesia,
University of California, San
Francisco (Dr Luce); and
Department of Critical Care,
Rhode Island Hospital, Brown
University, Providence
(Dr Levy).
D
tral Europe, whereas oral orders took preference in Southern Europe, Turkey, and Brazil. One third of Japanese
physicians said that they would not apply do-notresuscitate orders. Most participants from Japan, Turkey, the United States, Southern Europe, and Brazil chose
to treat the hypothetical patient with antibiotics if he/
she developed septic shock, whereas in Northern Europe, Central Europe, Canada, and Australia, terminal
withdrawal of mechanical ventilation and extubation were
the more commonly chosen responses.
Conclusions: In countries where intensive care medi-
cine is relatively well developed, considerable differences remain in physicians’ attitudes toward end-of-life
care in the intensive care unit. Substantial work remains if an international consensus on these issues is to
be reached.
Arch Intern Med. 2005;165:1970-1975
ISCUSSIONS ABOUT ENDof-life issues have become common, especially in the Western
medical literature. Advances in medical technology and therapies enable more lives to be saved but
sometimes may merely prolong the dying process. Recent studies1,2 have shown
that the exact timing of death is often under the control of the physicians who care
for the patient. This is particularly true in
the intensive care unit (ICU),3 where death
is commonly preceded by decisions not to
start aggressive therapy (withholding) or
to discontinue life-sustaining therapy
(withdrawing). The question of who
should be responsible for decision making is a difficult issue; the patient is often
unable to participate in this decision, and
the roles of the medical team, the relatives, and the legal system are highly variable in different parts of the world, add-
(REPRINTED) ARCH INTERN MED/ VOL 165, SEP 26, 2005
1970
ing to the variability of these end-of-life
decisions and the difficulty in achieving
an international consensus on these issues. Numerous reports exist on this
topic,4-13 and several surveys have been
conducted2,14-25; however, these surveys
were limited to national or geographic regions, and no large international survey has
been performed. As previous studies have
shown,14,17,18,20 substantial differences exist among European countries. Furthermore, the guidelines in the United States26
are also different from those within Europe.27,28 Although some would defend the
need for the development of an international consensus or a global system of ethics,3 this may not be achievable or even desirable. In a recent survey of physicians
involved in end-of-life care in 6 European countries and Australia, Miccinesi et
al29 reported that country was the strongest determinant of physician attitude toward end-of-life decisions, although the in-
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dividual physician characteristics of age, religious beliefs,
sex, and previous experience with dying patients were
also strong determinants. Other studies11,14,17,18,29,30 have
shown the strong influence of religion, culture, race, legal background, social factors, and tradition on attitudes toward end-of-life issues. In addition, these issues
are influenced by and change with temporal trends,11,14,17
as illustrated by the Hippocratic Oath, which recognized the importance of the principles of beneficence, nonmaleficience, and medical futility but did not discuss autonomy or distributive justice. During the last 4 decades,
autonomy and distributive justice have become increasingly predominant.
To better understand the international differences in
end-of-life decisions in the ICU, we conducted a simple
international survey by e-mail. The aim of the study was
to record current end-of-life attitudes of ICU physicians
in those parts of the world where the practice of intensive care medicine is fairly well developed.
METHODS
STUDY DESIGN
A list of e-mail addresses of individuals who had requested information regarding the International Symposium on Intensive Care and Emergency Medicine was provided by the meeting’s secretariat. This symposium (www.intensive.org), held
every year in Brussels, Belgium, is one of the largest international meetings in this field, with close to 5000 participants attending each year. We limited our list of addresses to physicians and to countries with more than 100 physicians in the
database and, at the end of 2003, invited physicians on this list
to reply to a simple questionnaire sent by e-mail. Two reminders were sent to those who did not reply to the first e-mail.
The questionnaire consisted of a case scenario and 4 questions with 3 to 5 optional answers (Table 1). The questionnaire was given in English, which is the official language of this
international symposium. The participants were invited to answer by e-mail, and it was guaranteed that they would be anonymous in the data analysis. We excluded answers received from
nonphysicians from the analysis. European countries were divided into 3 groups by geographic region: Northern Europe
(Denmark, Finland, the Netherlands, Sweden, and the United
Kingdom), Central Europe (Austria, Belgium, the Czech Republic, France, Germany, and Switzerland), and Southern Europe (Greece, Italy, Portugal, and Spain).
STATISTICAL ANALYSIS
Statistical analyses were performed using commercial software StatView 5.0 for Windows (SAS Institute Inc, Cary, NC).
A ␹2 test was used to compare groups. Multivariate statistical
analysis was also performed, using multiple correspondence
analyses. Briefly, the method consists of the analysis of the 2-way
contingency table in which the observed association between
the rows (the region of origin of the respondent) and the columns (the responses to the different options) is summarized
by the cell frequencies. The inference in correspondence analyses is whether certain levels of one characteristic (eg, region)
are associated with some levels of another characteristic (eg,
responses to the different options). Correspondence analysis
is a geometric technique for displaying the rows and columns
of this 2-way contingency table as vectors and points in lowdimensional space, such that the row vectors and column points
(REPRINTED) ARCH INTERN MED/ VOL 165, SEP 26, 2005
1971
Table 1. The Questionnaire
Case Scenario
A 55-year-old woman was resuscitated from cardiac pulmonary arrest
due to cardiac ischemic disease and admitted to the intensive care
unit (ICU) with severe postanoxic lesions. Twenty-four hours later,
she has decerebration movements and the evoked potentials are
absent. The consensus (including the senior neurologist) is that her
best possible outcome is a persistent vegetative state. She has no
close relative or advance directive.
Question 1. Which process do you follow to decide on the treatment
for this patient in the ICU?
1. Decide by yourself.
2. Decide after a consensus is reached with other physicians.
3. Decide after discussions involving other physicians and nurses.
4. Refer to the ethical committee in your hospital.
5. Refer to court.
Question 2. Is this process likely to result in do-not-resuscitate (DNR)
orders being applied in the event of recurrent cardiac arrest?
1. Yes, written DNR orders.
2. Yes, verbal DNR orders.
3. No.
Question 3. The patient remains absolutely stable for 5 days and,
although still receiving mechanical ventilation, can breathe
spontaneously. What would be the usual strategy in your institution?
1. Keep the patient in the ICU (with or without tracheostomy) and
start further interventions if a complication occurs.
2. Keep the patient in the ICU (with or without tracheostomy)—
“wait and see”—but withhold therapy if a complication occurs.
3. Keep the patient in the ICU and start increasing doses of
morphine or sedatives with the intent to decrease ventilatory
conditions (“terminal weaning”).
4. Perform a tracheostomy and transfer the patient to the general
ward for continued care.
5. Perform a tracheostomy and transfer the patient to the general
ward, but with the intent to stop enteral feeding.
Question 4. While the possible options are being considered, let us
imagine that the patient rapidly develops fever and septic shock,
presumably due to lung infection. What would likely be done in your
institution?
1. Maintain mechanical ventilation and start antibiotics and
vasopressors.
2. Maintain mechanical ventilation and start antibiotics but no
vasopressors.
3. Give morphine and reduce ventilatory conditions (“terminal
weaning”).
4. Extubate and then give morphine (“terminal extubation”).
are consistent with their associations in the table. The goal is
to obtain a global view of the data that is useful for interpretation. The overall ␹2 of the contingency table reflects the degree of departure from a purely random distribution between
the responses and the countries. If no relationship exists between the countries and the responses, the ␹2 will equal zero.
The correspondence analysis will partition the ␹2 in dimensions that correspond to different angles of view of the data set.
The first dimension is the best angle of view of the data, followed by the second dimension, and so on. Each dimension
reflects a percentage of inertia, which corresponds to the proportion of the ␹2 statistic explored by this dimension (ie, the
information contained in the data). The axis of the graph, labeled dimension, cannot be interpreted from a clinical standpoint. The advantage of the multivariate approach is to analyze the data globally and to take into account the correlation
among the variables, thus reducing bias in the results. P⬍.05
was considered statistically significant.
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Table 2. Numbers of Participants in the 21 Countries
Country or Region
No. (%) of
Participants
Response
Rate, %
United States
Canada
Australia
Northern Europe
Denmark
Finland
The Netherlands
Sweden
United Kingdom
Central Europe
Austria
Belgium
Czech Republic
France
Germany
Switzerland
Southern Europe
Greece
Italy
Portugal
Spain
Turkey
Brazil
Japan
Total
199 (10.1)
58 (3.0)
56 (2.9)
517 (26.4)
37 (1.9)
32 (1.6)
123 (6.3)
84 (4.3)
241 (12.3)
734 (37.4)
60 (3.1)
233 (11.9)
34 (1.7)
121 (6.2)
194 (9.9)
92 (4.7)
257 (13.1)
42 (2.1)
117 (6.0)
23 (1.2)
75 (3.8)
27 (1.4)
39 (2.0)
74 (3.8)
1961 (100)
66.3
64.4
62.9
56.6
44.6
62.7
54.4
68.3
56.0
54.9
50.8
55.7
53.1
48.6
57.4
60.9
46.0
36.8
49.6
29.9
56.8
46.6
69.6
81.3
56.1
RESULTS
STUDY PARTICIPANTS
From a total of 3673 valid addresses, 179 respondents
declared that they had no ICU responsibility. From the
remaining 3494 valid addresses, we received 1961 complete surveys (56.1%) from ICU physicians. The numbers and percentages of participants in each of the 21
countries represented are presented in Table 2. The largest numbers of participants were from the United Kingdom, Belgium, the United States, and Germany. The
percentage of participants for each region ranged from
46.0% in Southern Europe to 81.3% in Japan. For all questions, there was a statistically significant difference among
the countries and regions in the answers given (P⬍.001).
DECISION MAKING
The scenario describes the management of a patient in a
vegetative state due to anoxic encephalopathy after cardiac arrest with no family and no advance directives. The
first question dealt with the decision-making process. The
United States was the country with the largest proportion (45%) of respondents saying that they would ask for
an ethical consultant in the hospital or make a court referral. Fewer respondents in the United States and Canada
replied that they would make the decision alone or just
with other physicians (27% and 29%, respectively) than
in the other regions. Respondents from Northern and Central Europe replied more often than other areas that they
would involve nurses in such discussions (62% and 62%,
(REPRINTED) ARCH INTERN MED/ VOL 165, SEP 26, 2005
1972
respectively). This was particularly true in the United
Kingdom, France, and Switzerland, where approximately 80% of physicians involved nurses (83%, 80%, and
78%, respectively). Of respondents from Southern Europe, only 32% replied that they would involve nurses
(P⬍.001 vs Northern or Central Europe); percentages for
Turkey (41%), Brazil (38%), Japan (39%), and the United
States (29%) were similarly low.
DO-NOT-RESUSCITATE ORDERS
The second question dealt with do-not-resuscitate (DNR)
orders, for which a striking difference was noted among
regions (P⬍.001; Figure 1). More than 80% of physicians in Northern and Central Europe, North America, and
Australia said that they would be likely to apply written
DNR orders in the hypothetical case presented. In contrast, in Southern Europe, Turkey, and Brazil, oral DNR
orders were preferred. Japan was the country with the highest proportion (approximately one third of the respondents) who said that they would not apply DNR orders.
TREATMENT FOR A STABLE
VEGETATIVE PATIENT
Question 3 asked about the treatment of a patient in a
vegetative state. Participants from Japan and Turkey were
more likely to reply that they would continue full
support than participants from the other countries
(Figure 2). Australian and Canadian participants chose
terminal withdrawal of mechanical ventilation as their
response more commonly than participants from other
countries. Northern Europe had a greater tendency to
transfer patients to the general ward.
TREATMENT FOR SEPTIC SHOCK
IN A VEGETATIVE PATIENT
Question 4 raised the hypothesis that the vegetative patient developed septic shock (Figure 3). Choice of the
full-support option ranged from 2% of respondents in Australia to 65% in Greece. The option to give antibiotics,
with or without vasopressors (option 1 or 2), was selected by most physicians in Japan (96%), Turkey (81%),
the United States (65%), Southern Europe (62%), and
Brazil (59%) (P⬍.001 vs other regions), whereas in Northern Europe, Central Europe, Canada, and Australia, terminal withdrawal of mechanical ventilation and extubation were more commonly chosen.
COMMENT
This simple survey revealed striking international differences in the attitudes of ICU physicians toward endof-life issues in adult patients. In our scenario-based questionnaire, we presented a patient with no family and no
advance directives so that the responsibility for decision
making would be on the physician or health care team
rather than the family. Under these conditions, more physicians from the United States thought that it could be
helpful to refer outside the ICU than other countries; it
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Would Apply
Written Orders
Would Apply
Verbal Orders
Would Not Apply
DNR Orders
100
Respondents, %
80
60
40
20
0
United States
Canada
Australia
Northern Europe
Central Europe
Southern Europe
Turkey
Brazil
Japan
Region
Figure 1. Percentage of respondents in the various regions for question 2 related to the application of do-not-resuscitate (DNR) orders.
(REPRINTED) ARCH INTERN MED/ VOL 165, SEP 26, 2005
1973
0.30
Transfer
General Ward
Dimension 2 (31% of Inertia)
is possible that the legal environment in the United States
may have some influence on these decisions.31 In Europe, physicians seem to prefer to decide within the ICU
team, rather than involving outside ethical or legal advisers. Participants in Northern and Central Europe replied that they were more likely to involve nurses in the
decision making than were respondents from Southern
European countries. Notably, participants from the United
States were the least likely to report involving nurses.
The application of DNR orders varied with geographic region. Respondents from Australia, Canada, the
United States, and Northern and Central Europe generally replied that they would apply written DNR orders.
However, Turkey, Southern Europe, and Brazil preferred the oral DNR orders. A previous European study17
also showed that DNR orders were less commonly written in Southern than in Northern and Central Europe.
In Japan, approximately one third of respondents would
not apply DNR orders at all.
Participants from Turkey and Japan chose aggressive
therapy with continued full support more often than participants from other countries. In Northern Europe, Central Europe, the United States, and Brazil, passive withdrawal of therapy, such as transfer to the general ward,
was preferred over stopping feeding, extubating, or decreasing ventilator conditions. When a serious septic complication occurred in this hypothetical patient, respondents from Southern Europe, Turkey, Canada, the United
States, Brazil, and Japan usually treated the complication
with antibiotics, and Japanese physicians were also likely
to give vasopressors. In contrast, in Northern and Cen-
Southern Europe
Northern Europe
No Escalation
0
Central Europe
Brazil
Terminal
Withdrawal
–0.30
United
States
Turkey
Australia
Canada
Japan
–0.60
Do Everything
–1.00
–0.50
0
0.50
1.00
Dimension 1 (62% of Inertia)
Figure 2. Attitudes related to question 3 regarding a stable vegetative
patient. Vectors show the direction to the options. Percentages show the
variance of the plots explained by the principal component. The proximity
between points (regions) and the tip of a vector (responses) indicates
similarity between the end-of-life attitudes in these countries (see the
“Statistical Analysis” subsection in the “Methods” section for details).
Circles indicate answer by region; triangles, answer by option.
tral Europe, respondents were more likely to reply that they
would actively withdraw therapy. In Australian respondents, the occurrence of sepsis did not alter the treatment
plan. These data confirm prior studies of geographic difWWW.ARCHINTERNMED.COM
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80
80
A
60
Respondents, %
Respondents, %
60
B
40
20
40
20
0
0
s
ited
Un
te
Sta
alia
ada
ope
ope
ope
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Eur
Eur
Eur
Can
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e
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Region
80
zil
Bra
Jap
key
Tur
zil
Bra
an
Jap
an
Region
80
C
D
60
Respondents, %
60
Respondents, %
key
Tur
40
20
40
20
0
0
tes
ta
dS
ite
Un
ada
Can
e
pe
ope
r op
uro
Eur
l Eu
nE
ern
tra
her
n
h
t
t
e
r
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C
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st
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Region
Region
Figure 3. Responses to question 4 related to treatment for septic shock in a patient in a vegetative state. A, Physicians who would recommend terminal
extubation; B, physicians who would recommend terminal withdrawal of mechanical ventilation; C, physicians who would recommend only antibiotics;
and D, physicians who would do everything.
ferences within Europe17,18 and studies of variability within
the United States32 and Canada.15 In addition, our data show
that these geographic differences continue to persist and
that they extend around the world. Furthermore, the multiple correspondence analyses show that the countries do
not all lie on 1 axis, suggesting variability in the responses within each country depending on individuals.
Our study has several limitations. First, the respondents were not a randomly selected sample of all critical
care physicians because such a database does not exist.
Rather, we used a list of potential participants at a major
international critical care conference held annually in Europe. This may have resulted in a distance factor; respondents from Belgium and neighboring countries may be
different from those coming from farther away. An al(REPRINTED) ARCH INTERN MED/ VOL 165, SEP 26, 2005
1974
ternative option would have been to use databases of regional scientific societies, but logistically this would have
been much more difficult. Physicians attending such a
conference may reflect a self-selected population with different attitudes from other critical care physicians. However, we would expect that the bias would be toward physicians with a more global perspective. This would suggest
that true differences in different regions might actually
be larger than found in this study. Second, to minimize
the length of the survey and maximize the response rate,
we have no information on the respondents’ backgrounds, age, sex, position in their hospital, or religion,
and unidentified differences among countries in these subgroups may potentially have influenced the results. Third,
the case scenario was by intent somewhat simplistic. Any
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influence of relatives or the patients themselves on these
decisions could not be taken into account. Moreover, as
in all questionnaire studies, it is not always possible to
provide an appropriate answer for all situations, and other
options may have been preferred if they had been offered to the respondents. Fourth, the questionnaire was
developed by the authors and did not undergo reliability or validity testing. Finally, although e-mail provides
a rapid means of communication, answers are not really
anonymous, which may have prevented some physicians from participating.
Nevertheless, this international survey presents an upto-date indication of physicians’ attitudes toward endof-life decision making in the ICU. Clearly, these attitudes differ not only in various regions of the globe but
also within each country. Physicians’ attitudes surrounding end-of-life decision making in the ICU remain highly
variable despite widespread discussion and publication
of guidelines and recommendations.26-28 This is one area
of intensive care medicine in which a global, uniform approach is difficult if not impossible to apply at this time.
These issues are hard to measure objectively, and it is
therefore difficult to determine best practice, unlike situations with clearer outcome measures such as the treatment of patients with acute myocardial infarction. Best
practice in end-of-life care could perhaps be defined in
terms of the society (expressed through local laws and
social customs and beliefs), the profession (expressed
through guidelines and consensus recommendations), or
a more global view (where universal standards are identified and then applied to individual situations). However, although it is important to understand why differences exist, it may not be necessary or even appropriate
to have an international consensus. Whether the international critical care community can, or should, work
toward a global consensus on these issues regarding endof-life care in the ICU remains unclear. Although we believe that there needs to be some global consensus on basic ethical principles, determining which aspects should
be treated as globally definable and which must be left
to individual countries, regions, or cultures requires further work. Continuing discussion among critical care physicians, based on results of surveys such as this, is needed
to better understand the importance of international differences in end-of-life decision making in the ICU.
Accepted for Publication: May 17, 2005.
Correspondence: Jean-Louis Vincent, MD, PhD, Department of Intensive Care Medicine, Erasme Hospital, Free
University of Brussels, Route de Lennik 808, B-1070 Brussels, Belgium ([email protected]).
Financial Disclosure: None.
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