HILE THE PRINCIPLE THAT dying patients should be treated with respect and compassionisbroadlyaccepted among health care professionals, medical practices for end-of-life care differ around the world. In the United States, medicine has moved from a paternalistic model to one that promotes autonomy and self-determination. 1,2 Patient expectations and preferences now help shape end-of-life practices, limiting the use of technologies that may prolong dying rather than facilitate recovery. 1,2 In Europe, patient-physician relationships are still somewhat paternalistic. 3-5 Different cultures and countries deal in diverse ways with the ethical dilemmas arising as a consequence of the wider availability of life-sustaining therapies. 3,4,6 Some have not adopted the Western emphasis on patient autonomy or methods of terminating life support. 3,4,6 In the past, patients died in intensive care units (ICUs) despite ongoing aggressive therapy. 7 Theoretical discussions 7 and attitudes of critical care Author Affiliations and the members of the Ethicus Study Group are listed at the end of this article.

Great differences in end-of-life practices in treating the critically ill around the world warrant agreement regarding the major ethical principles. This analysis determines the extent of worldwide consensus for end-of-life practices, delineates where there is and is not consensus, and analyzes reasons for lack of consensus. Critical care societies worldwide were invited to participate. Country coordinators were identified and draft statements were developed for major end-of-life issues and translated into six languages. Multidisciplinary responses using a web-based survey assessed agreement or disagreement with definitions and statements linked to anonymous demographic information. Consensus was prospectively defined as >80% agreement. Definitions and statements not obtaining consensus were revised based on comments of respondents, and then translated and redistributed. Of the initial 1,283 responses from 32 countries, consensus was found for 66 (81%) of the 81 definitions and statements; 26 (32%) had >90% agreement. With 83 additional responses to the original questionnaire (1,366 total) and 604 responses to the revised statements, consensus could be obtained for another 11 of the 15 statements. Consensus was obtained for informed consent, withholding and withdrawing life-sustaining treatment, legal requirements, intensive care unit therapies, cardiopulmonary resuscitation, shared decision making, medical and nursing consensus, brain death, and palliative care. Consensus was obtained for 77 of 81 (95%) statements. Worldwide consensus could be developed for the majority of definitions and statements about end-of-life practices. Statements achieving consensus provide standards of practice for end-of-life care; statements without consensus identify important areas for future research.

Significant differences associated with religious affiliation and culture were observed for the type of end of life decision, the times to therapy limitation and death, and discussion of decisions with patient families.

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.

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