Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe

Bernhard Wernly, Richard Rezar, Hans Flaatten, Michael Beil, Jesper Fjølner, Raphael Romano Bruno, Antonio Artigas, Bernardo Bollen Pinto, Joerg C Schefold, Malte Kelm, Sviri Sigal, Peter Vernon van Heerden, Wojciech Szczeklik, Muhammed Elhadi, Michael Joannidis, Sandra Oeyen, Georg Wolff, Brian Marsh, Finn H Andersen, Rui MorenoSusannah Leaver, Sarah Wernly, Ariane Boumendil, Dylan W De Lange, Bertrand Guidet, Christian Jung

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BACKGROUND: Previous studies reported regional differences in end-of-life care (EoLC) for critically ill patients in Europe.

OBJECTIVES: The purpose of this post-hoc analysis of the prospective multi-centre COVIP study was to investigate variations in EoLC practices among older patients in intensive care units during the coronavirus disease 2019 pandemic.

METHODS: A total of 3105 critically ill patients aged 70 years and older were enrolled in this study (Central Europe: n = 1573; Northern Europe: n = 821; Southern Europe: n = 711). Generalised estimation equations were used to calculate adjusted odds ratios (aOR) to population averages. Data were adjusted for patient-specific variables (demographic, disease-specific) and health economic data (GDP, health expenditure per capita). The primary outcome was any treatment limitation, and 90-day-mortality was a secondary outcome.

RESULTS: The frequency of the primary endpoint (treatment limitation) was highest in Northern Europe (48%), intermediate in Central Europe (39%), and lowest in Southern Europe (24%). The likelihood for treatment limitations was lower in Southern than in Central Europe (aOR 0.39; 95%CI 0.21-0.73; p = 0.004), even after multivariable adjustment, whereas no statistically significant differences were observed between Northern and Central Europe (aOR 0.57; 95%CI 0.27-1.22; p = 0.15). After multivariable adjustment, no statistically relevant mortality differences were found between Northern and Central Europe (aOR 1.29; 95%CI 0.80-2.09; p = 0.30) or between Southern and Central Europe (aOR 1.07; 95%CI 0.66-1.73; p = 0.78).

CONCLUSION: This study shows a north-to-south gradient in rates of treatment limitation in Europe, highlighting the heterogeneity of EoLC practices across countries. However, mortality rates were not affected by these results. This article is protected by copyright. All rights reserved.

Original languageEnglish
Pages (from-to)438-449
JournalJournal of Internal Medicine
Issue number3
Early online date5 Apr 2022
Publication statusPublished - Sep 2022


  • COVID-19
  • critical care
  • frail elderly
  • public health systems research
  • resuscitation orders


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