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The impact of regional culture on intensive care end of life decision making: an Israeli perspective from the ETHICUS study
  1. F D Ganz1,
  2. J Benbenishty2,
  3. M Hersch3,
  4. A Fischer4,
  5. G Gurman5,
  6. C L Sprung6
  1. 1Hadassah-Hebrew University School of Nursing, Jerusalem, Israel
  2. 2Hadassah Medical Organization, Jerusalem, Israel
  3. 3Intensive Care Unit, Sharee Zedek Medical Center, Jerusalem and Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva, Israel
  4. 4Ben Gurion University Hospital, Beersheva, Israel
  5. 5Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva, Israel
  6. 6Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
  1. Correspondence to:
 F D Ganz
 Hadassah-Hebrew University School of Nursing, Kiryat Hadassah, PO Box 12000, Jerusalem, Israel; freda{at}


Background: Decisions of patients, families, and health care providers about medical care at the end of life depend on many factors, including the societal culture. A pan-European study was conducted to determine the frequency and types of end of life practices in European intensive care units (ICUs), including those in Israel. Several results of the Israeli subsample were different to those of the overall sample.

Objective: The objective of this article was to explore these differences and provide a possible explanation based on the impact of culture on end of life decision making.

Method: All adult patients admitted consecutively to three Israeli ICUs (n = 2778) who died or underwent any limitation of life saving interventions between 1 January 1999 and 30 June 2000 were studied prospectively (n = 363). These patients were compared with a similar sample taken from the larger study (ethics in European intensive care units: ETHICUS) carried out in 37 European ICUs. Patients were followed until discharge, death, or 2 months from the decision to limit therapy. End of life decisions were prospectively organised into one of five mutually exclusive categories: cardiopulmonary resuscitation (CPR), brain death, withholding treatment, withdrawing treatment, and active shortening of the dying process (SDP). The data also included patient characteristics (gender, age, ICU admission diagnosis, chronic disorders, date of hospital admission, date and time of decision to limit therapy, date of hospital discharge, date and time of death in hospital), specific therapies limited, and the method of SDP.

Results: The majority of patients (n = 252, 69%) had treatment withheld, none underwent SDP, 62 received CPR (17%), 31 had brain death (9%), and 18 underwent withdrawal of treatment (5%). The primary reason given for limiting treatment was that the patient was unresponsive to therapy (n = 187). End of life discussions were held with 132 families (36%), the vast majority of which revolved around withholding treatment (91% of the discussions) and the remainder concerned withdrawing treatment (n = 11, 9%).

There was a statistically significant association (χ2 = 830.93, df=12, p < 0.0001) between the type of end of life decision and region—that is, the northern region of Europe, the central region, the southern region, and Israel.

Conclusions: Regional culture plays an important part in end of life decision making. Differences relating to end of life decision making exist between regions and these differences can often be attributed to cultural factors. Such cultures not only affect patients and their families but also the health care workers who make and carry out such decisions.

  • CPR, cardiopulmonary resuscitation
  • DNR, do not resuscitate
  • ETHICUS, ethics in European intensive care units
  • ICU, intensive care unit
  • SDP, shortening of the dying process
  • culture
  • end of life decision making
  • intensive care
  • Israel

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  • This study was conducted as a substudy under the ethics in European intensive care units (ETHICUS) study funded by the European Concerted Action project and by the European Commission (contract PL963733), the Chief Scientist’s Office of the Ministry of Health, Israel (grant no. 4226), and the European Society of Intensive Care Medicine.

  • Conflict of interest: none declared

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