End-of-life decision disparities according to the gross national income in critically ill patients: a secondary analysis of the ETHICUS-2 study

Martin‑Loeches et al. Annals of Intensive Care https://doi.org/10.1186/s13613-025-01419-1 (2025) 15:29 Annals of Intensive Care Open Access RESEARCH End‑of‑life decision disparities according to the gross national income in critically ill patients: a secondary analysis of the ETHICUS‑2 study Ignacio Martin‑Loeches1* , Charles L. Sprung2, Eric Wolsztynski3,4, Rachael Cusack1, Suzana Margareth Lobo5, Alessandro Protti6,7 and Alexander Avidan2 Abstract Aim This study aimed to evaluate the association of end-of-life decisions and time to death in a global cohort of critically ill patients who participated in the international study on end-of-life practices in intensive care units (ICU) (Ethicus-2 study). Methods A post hoc analysis was conducted on data from a worldwide observational study that prospectively recruited adult ICU patients who died between September 1, 2015, and September 30, 2016, from 199 ICUs in 36 countries. Results The end-of-life pathways of 10,547 ICU non-survivors were s analysed. Patients in high-income countries exhibited a significantly shorter time to death compared to those from middle-income countries. Additionally, therapeutic decisions were found to have a significant but varied association with the length of ICU stay across gross national income (GNI) groups. Specifically, patients in high-income countries with no decision had the shortest length of stay (LOS) overall. However, with‑ drawing or withholding life-sustaining treatment led to longer LOS in both middle and high GNI countries. Conclusion This study’s findings highlight the need for uniformity in global end-of-life decision-making. Outcomes are significantly associated with gross national income (GNI). Moreover, patients in high-income nations tend to have shorter ICU stays before death. Keywords Intensive care, End-of-life, Hospital mortality, Gross national income, Life-sustaining measures *Correspondence: Ignacio Martin‑Loeches 1 Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James’ Hospital, Dublin D08 NHY1, Ireland 2 Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel 3 School of Mathematical Sciences, University College Cork, Western Gateway Building, Western Road, Cork T12 XF62, Ireland 4 Insight SFI Centre for Data Analytics, University College Cork, Western Gateway Building, Western Road, Cork T12 XF62, Ireland 5 Unidade de Terapia Intensiva, Hospital de Base, Faculdade de Medicina de São José Do Rio Preto, São José do Rio Preto, SP, Brasil 6 IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy 7 Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy © The Author(s) 2025. 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Annals of Intensive Care (2025) 15:29 Take home message End-of-life decision-making is very different according to the regions, and in high-income nations, patients stay shorter preceding death. Introduction Global mortality rates in intensive care units (ICUs) average between 10 and 25% [1, 2]. Acute illness often accounts for mortality shortly after ICU admission, whereas patients who succumb after an extended length of stay (LOS) typically develop complications leading to delayed mortality [3–5]. The accumulation of multimorbidity, organ failure, and ICU-related complications can be anticipated [6], prompting physicians to engage in decision-making processes regarding end-of-life care, frequently involving the withholding or withdrawing of life-sustaining measures [6]. The organisation of ICUs plays a crucial role in determining morbidity and mortality [8, 9]. Previous studies have revealed an inverse correlation between in-hospital mortality and a country’s gross national income (GNI) [10]. Moreover, GNI positively correlates with increased ICU or hospital LOS preceding death [6]. Thanks to significant advances in modern medicine, it is now possible to sustain and support vital organ function beyond the point where a patient could be expected to return to an acceptable quality of life. Consequently, managing the dying process has become necessary for physicians and other ICU team members, including nurses and social workers [7]. However, end-of-life decisions in the ICU are complex processes. Decision-makers must consider several factors, including illness severity, physiological reserve, pre-morbid conditions, frailty, patients’ wishes, and family beliefs [1]. The limitation of life-sustaining therapy or refocusing patient care goals toward comfort and dignity in those unlikely to survive their illness is a common practice in the ICU [8–12]. Up to 12% of health expenditure in high-income countries is allocated to less than 1% of people who die in a given year [13]. The results of the Ethicus-2 study identified significant worldwide variations in patterns of end-of-life management [14]. We hypothesised that there is an association between GNI and end-of-life decisions and practices worldwide. Materials and methods This study constitutes a pre-defined post hoc analysis of data collected globally during end-of-life practices in intensive care units (ICUs) as part of the Ethicus-2 study [14]. Ethicus-2 was a prospective, multinational, observational study that included consecutive admissions to adult ICUs worldwide. Patients who died or had any limitation of life-sustaining treatment were included Page 2 of 10 in the study. The limitation of life-sustaining therapy was defined as the withholding or withdrawing of lifesustaining medical interventions or active shortening of the dying process [14]. The study encompassed patients admitted to 199 ICUs across 36 countries on five continents. Full details regarding the methodology and definitions have been previously published [14]. Patients Non-survivors with complete data on ICU mortality and time-to-death available were included in the analysis. Patients who remained alive after 60 days in the ICU were considered survivors for this analysis. Patients were categorised into thre (...truncated)