The impact of religion on changes in end-of-life practices in European intensive care units: a comparative analysis over 16 years

Intensive Care Med https://doi.org/10.1007/s00134-023-07228-z ORIGINAL The impact of religion on changes in end‑of‑life practices in European intensive care units: a comparative analysis over 16 years Joerg C. Schefold1* , Livio Ruzzante1* , Charles L. Sprung2, Anastasiia Gruber3, Eldar Soreide4, Joseph Cosgrove5, Sudakshina Mullick6, Georgios Papathanakos7, Vasilios Koulouras7, Paulo Azevedo Maia8, Bara Ricou9, Martin Posch3, Philipp Metnitz3, Hans‑Henrik Bülow10 and Alexander Avidan2 on behalf of the ETHICUS II Study Group © 2023 The Author(s) Abstract Purpose: Religious beliefs affect end-of-life practices in intensive care units (ICUs). Changes over time in end-of-life practices were not investigated regarding religions. Methods: Twenty-two European ICUs (3 regions: Northern, Central, and Southern Europe) participated in both Ethicus-1 (years 1999–2000) and Ethicus-2 studies (years 2015–2016). Data of ICU patients who died or had limitations of life-sustain‑ ing therapy were analysed regarding changes in end-of-life practices and patient/physician religious affiliations. Frequen‑ cies, timing of decision-making, and religious affiliations of physicians/patients were compared using the same definitions. Results: In total, 4592 adult ICU patients (n = 2807 Ethicus-1, n = 1785 Ethicus-2) were analysed. In both studies, patient and physician religious affiliations were mostly Catholic, Greek Orthodox, Jewish, Protestant, or unknown. Treating physi‑ cians (but not patients) commonly reported no religious affiliation (18%). Distribution of end-of-life practices with respect to religion and geographical regions were comparable between the two studies. Withholding [n = 1143 (40.7%) Ethicus-1 and n = 892 (50%) Ethicus-2] and withdrawing [n = 695 (24.8%) Ethicus-1 and n = 692 (38.8%) Ethicus-2] were most com‑ monly decided. No significant changes in end-of-life practices were observed for any religion over 16 years. The number of end-of-life discussions with patients/ families/ physicians increased, while mortality and time until first decision decreased. Conclusions: Changes in end-of-life practices observed over 16 years appear unrelated to religious affiliations of ICU patients or their treating physicians, but the effects of religiosity and/or culture could not be assessed. Shorter time until decision in the ICU and increased numbers of patient and family discussions may indicate increased awareness of the importance of end-of-life decision-making in the ICU. Keywords: End of life, Intensive care units, Religion, Withholding life-sustaining treatments, Withdrawing lifesustaining treatments, Active shortening of the dying process *Correspondence: ; 1 Department of Intensive Care Medicine, Inselspital, University of Bern, Bern, Switzerland Full author information is available at the end of the article Joerg C. Schefold and Livio Ruzzante shared first authorship. The members of the ETHICUS II Study Group are listed in Acknowledgements. Introduction Religion and religious beliefs may affect end-of-life practices and decisions in intensive care units (ICUs) [1]. End-of-life decision-making was shown to change over time [2] and may vary according to geographical regions, contributing to major worldwide differences [3]. Many ICU physicians may not be aware of the potential role played by religious beliefs and regional/cultural values regarding end-of-life decision-making [4]. While improved ICU physician–patient communication may result in better understanding of the role of the patients’ religious beliefs, traditions, and culture, understanding patients’ wishes may lead to improved patient-centred care and respect for patient autonomy providing an improved basis for individual treatment goals in ICUs [5]. In the Ethicus-1 study (1999–2000), we observed significant differences associated with religious affiliations and regional variations regarding types of end-of-life practices (including withholding or withdrawing of lifesustaining therapy, shortening of the dying process, brain death, and cardio-pulmonary resuscitation), times to therapy limitation and death, and discussion of decisions with patient families [6]. There is a clear need for a better understanding of changes in religion and culture over time; however, such research is lacking. Nevertheless, with a more thorough understanding of changes over time in different regions, it would be possible to generate the evidence necessary to better understand and consider different aspects of endof-life care [7]. The fact that such research may generally be difficult to perform and,e.g. patient religious affiliation often unknown in (e.g. unconscious) critically ill patients, it may also explain why several end-of-life studies worldwide have investigated the role of religion and/ or culture mainly via (self-reported) questionnaires [8, 9]. Few studies have investigated changes in end-of-life practices over time [3], and none have evaluated religion as a potential cause for practice changes. Therefore, using the same definitions as in Ethicus-1, the goal of this study was to investigate whether there was a change in the influence of religious affiliation of physicians and patients on end-of-life practices in 22 European ICUs over the course of 16 years. Since religion was previously shown to impact on whether doctors decide to withdraw or withhold life-sustaining treatments [10], we were particularly interested whether a change over time regarding “active” (i.e. withdrawing, WD and shortening of the dying process, SDP) vs. “passive” (i.e. withholding, WH) limitations has occurred. Methods The current study is a preplanned sub-investigation of the Ethicus-2 ICU end-of-life practices worldwide study [2]. Take‑home message Religious beliefs and practices can influence end-of-life decisionmaking. However, changes in end-of-life practices observed over 16 years appear unrelated to religious affiliations of patients or their treating physicians. Shorter time until decision in intensive care units and increased numbers of discussions with patients and their families may indicate increased awareness of the importance of end-of-life decision-making in intensive care. Data from European ICUs participating in both Ethicus-1 [10] and Ethicus-2 [2] studies were analysed using the same methods. Patients were enrolled in Ethicus-2 during a self-selected 6-month observational period between September 1, 2015 and September 30, 2016. This study analysed the influence of religious affiliation of physicians and patients on end-of-life practices. Data from ICU patients of centres participating in both the Ethicus-1 and Ethicus-2 studies were analysed. Patients were followed up until ICU discharge, death, or 2 months from the first decision to limit treatment. These were selected from 22 European ICUs which participated in both Ethicus-1 and Ethicus-2 studies. Further details are given elsewhere [2]. Data recorded Patient characteristics i (...truncated)