2 In comparison, 10% of patients who die in hospitals in the United Kingdom are cared for in ICUs prior to their death.3 This is probably due to fewer available ICU beds.4 A few decades ago, patients died in the ICU after undergoing

cardiopulmonary resuscitation (CPR).5 Today, most patients dying in ICU do so after forgoing life-prolonging therapies.5–8 Many critically ill patients are initially admitted to the ICU with a prospect of being saved, but when this is not possible a CP-673451 in vivo change in the goal to palliative care should occur. This change has been described Inhibitors,research,lifescience,medical as moving from cure to comfort.9 This change is one of the most difficult decisions faced by intensive care professionals. There is a spectrum of end-of-life care options from full continued care, withholding treatment, withdrawing treatment, and active life-ending procedures (Figure 1). These categories were highlighted Inhibitors,research,lifescience,medical in the Ethicus Study.7 Full continued care involves all aggressive treatments,

including such therapies as mechanical ventilation, vasopressors, and cardiopulmonary resuscitation (CPR).7 Withholding treatment was defined as a decision not to start or increase Inhibitors,research,lifescience,medical a life-sustaining therapy, for example, not starting a vasopressor or performing CPR. Withdrawing treatment was defined as a decision actively to stop a life-sustaining treatment being given.7 Active shortening of the dying process was Inhibitors,research,lifescience,medical defined as a circumstance in which someone performed an act with a specific intent of shortening the dying process, for example, giving an intentional overdose of anesthetic or potassium chloride.7 Figure 1. Spectrum of End-of-Life Decisions. END-OF-LIFE DECISION-MAKING End-of-life decisions are made daily in hospitals and ICUs around the world. Some common triggers

for end-of-life decisions include severe neurological disorders (intraventricular hemorrhage or massive stroke), unresponsiveness to aggressive therapies (continued Inhibitors,research,lifescience,medical hypotension despite maximal inotropic support), multi-organ system failure, or irreversible conditions. End-of-life decision-making can be influenced by numerous variables. For example, differences in location (Europe, America, Israel),6,7,10 religious and regional differences,11,12 and differences amongst attitudes of patients, families, physicians, and nurses.13 Edoxaban Wide variations of end-of-life decision-making exist between countries, within countries, within cities, and even within the same ICU.10 This can be explained by different physician values. In the United States, medicine has long ago moved away from a paternalistic model to one that promotes autonomy and self-determination.14 Patient expectations and wishes are considered regarding end-of-life decisions. In Northern Europe, patient–physician relationships also promote autonomy, but the further south and east you go in Europe, the relationship becomes more paternalistic.