October 13, 2015

Intensive Care Medicine journal



The main aim of intensive therapy is to increase the positive outcomes of diseases and illnesses, and intensive therapy has helped countless patients to get discharged from the ICU alive. However, one of the major disadvantages of this treatment include the possibility of keeping patients, who will ultimately die from their illness, alive for a longer period of time. ICU healthcare professionals therefore often have to make decisions about withholding or withdrawing life-sustaining therapy, but prior studies have identified variability in decision-making at many levels.

In this recent systematic review published in Intensive Care Medicine, Mark and colleagues, sought to examine regional, national, inter-hospital and inter-physician variability in the withholding and withdrawal of life-sustaining treatment in adult ICU patients. The investigators searched three electronic databases for peer-reviewed papers, and netted a total of 56 observational and interventional studies from 1990-2014 to include in the review. The mean prevalence of withdrawal of life-sustaining treatment for patients who died varied from 0-84% (SD 24%). Withholding of life-sustaining treatment had likewise variations with means between 5-67% (SD 19%). Substantial variability was found both between world regions, countries, individual ICUs within countries, as well as individual intensivists within one ICU.

This study adds to the knowledge of decision-making in the ICU. As discussed by the authors, the substantial variability also found within individual ICUs can hardly be explained by regional or religious reasons only. This indicates that education in and focus on standardised approaches to limitation of life-sustaining treatment could improve ICU care.

Limitations of the review include heterogeneity of data, underrepresentation of regions outside North America and Europe, and exclusion of non-English-language papers.

This article review was submitted by Hanne Irene Jensen, member of the ESICM Ethics Section and the Journal Review Club.


Mark NM et al. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med. 2015; 41:1572-1585.

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