OBJECTIVES: The practice of limiting life-sustaining therapy (LST) at end-of-life is widespread globally. The goal of this study was to evaluate whether patient's age influences end-of-life limitations overall and of various LST in ICUs worldwide. DESIGN: Multinational, multicenter, prospective observational study. SETTING: One hundred ninety-nine ICUs in 36 countries worldwide. PATIENTS: Consecutive adult patients admitted to ICUs who died and/or had LST limitations (withholding, withdrawing, or active shortening of the dying process) were included during a 6-month period between September 2015 and September 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were grouped: younger than 65 years, 65-79 years old, and 80 years old or older. A total of 12,200 patients were included. In multivariate logistic regression analysis, odds ratio (OR) for any LST limitation in the 80 years old or older group was higher than in younger than the 65 years old group (OR 1.47 [95% CI, 1.22-1.76], p < 0.001). When stratified by region, this association was significant in Central and Southern Europe (OR 1.56 [95% CI, 1.11-2.20], p = 0.037 and OR 2.23 [95% CI, 1.58-3.17], p < 0.001, respectively), but not in the other regions. The proportion of withholding therapy of each LST was highest in the group of individuals 80 years or older, whereas the proportion of withdrawing therapy was highest in the group younger than 65 years. The 80-year-old or older group also had a shorter time from ICU admission to first limitation. The predominant reason for any LST limitation in all age groups was unresponsiveness to maximal therapy, followed by neurologic and chronic diseases. Patient age was rarely the primary reason for limitations for all groups. CONCLUSIONS: End-of-life limitations were higher in patients 80 years or older compared to those 65 years old or younger, with regional variations. The main reasons for limitations were comparable across age groups, with age not being the primary reason.

Advanced haemodynamic monitoring of cardiac index is restricted to selected high-risk cases, leaving most patients undergoing major surgery without real-time assessment. We aimed to develop and internally validate a simplified bedside score for continuous, minute-by-minute screening of low cardiac index using routinely available parameters. Retrospective single-centre study of adults undergoing major abdominal surgery with advanced haemodynamic monitoring (January 2023 to February 2026). Low cardiac index was defined as pulse contour cardiac index < 2.2 l.min− 1.m− 2. The dataset was split 80/20 at the patient level. Twelve candidate features were ranked using SHapley Additive exPlanations (SHAP) values; the top five were used to fit a generalised linear mixed model, yielding the integer-weighted Low Cardiac Index (LCI) score. A rule-out threshold (sensitivity ≥ 0.90) was selected, and test-set performance was evaluated with patient-level cluster bootstrap. The analysis cohort comprised 136 patients and 42,346 timepoints (15.5

BACKGROUND:Videolaryngoscopy has significantly improved the management of unanticipated difficult airways and replaced other intubation techniques. The goal of this study was to identify the indications for using videolaryngoscopy and fiberoptic bronchoscopy for adult patients, where direct laryngoscopy is the standard intubation technique. METHODS:Over a one-year period from January to December 2018, anesthesiologists were surveyed on their reasons for using a videolaryngoscope or fiberoptic bronchoscope for tracheal intubations. Additionally, retrospective data on all direct laryngoscopy intubations were collected for the same period from the anesthesia information management system. RESULTS:Out of 6251 tracheal intubations with direct laryngoscopy and 502 with videolaryngoscopy or fiberoptic bronchoscopy, data from 450 (89.6%) cases were collected. We excluded 46 cases where videolaryngoscopy and fiberoptic bronchoscopy were used for non-airway management reasons, resulting in 404 cases for analysis. Videolaryngoscopy was initially used in 356 (88.1%) patients. The primary reasons for using videolaryngoscopy or fiberoptic bronchoscopy were anticipated difficult intubation (218, 54.0%) and cervical pathology (109, 27.0%). Among the 42 cases of unanticipated failed direct laryngoscopy, videolaryngoscopy was used in 41 cases and fiberoptic bronchoscopy in 1 case. The overall rate of unanticipated failed direct laryngoscopy was 0.7%. CONCLUSIONS:The routine use of videolaryngoscopy and fiberoptic bronchoscopy for anticipated difficult tracheal intubations led to a very low incidence of unanticipated failed tracheal intubations with direct laryngoscopy. Therefore, routinely using more expensive videolaryngoscopes for all intubations would prevent only very small numbers of unanticipated failed direct laryngoscopic intubations and is not financially justified.

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, withdrawing 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.

Background: ICU nurses are most frequently at the patient's bedside, providing care for both patients and family members. They perform an essential role and are involved in decision-making. Despite this, research suggests that nurses have a limited role in the end-of-life decision-making process and are occasionally not involved. Objective: Explore global ICU nurse involvement in end of life decisions based on the physician's perceptions and sub-analyses from the ETHICUS-2 study. Design: This is a secondary analysis of a prospective multinational, observational study of the ETHICUS-2 study. Setting: End of life decision-making processes in ICU patients were studied during a 6-month period between Sept 1, 2015, and Sept 30, 2016, in 199 ICUs in 36 countries. Intervention: None. Methods: The ETHICUS II study instrument contained 20 questions. This sub-analysis addressed the four questions related to nurse involvement in end-of-life decision-making: Who initiated the end-of-life discussion? Was withholding or withdrawing treatment discussed with nurses? Was a nurse involved in making the end-of-life decision? Was there agreement between physicians and nurses? These 4 questions are the basis for our analysis. Global regions were compared. Results: Physicians completed 91.8 % of the data entry. A statistically significant difference was found between regions (p < 0.001) with Northern Europe and Australia/New Zealand having the most discussion with nurses and Latin America, Africa, Asia and North America the least. The percentages of end-of-life decisions in which nurses were involved ranged between 3 and 44 %. These differences were statistically significant. Agreement between physicians and nurses related to decisions resulted in a wide range of responses (27-86 %) (p < 0.001). There was a wide range of those who replied "not applicable" to the question of agreement between physicians and nurses on EOL decisions (0-41 %). Conclusion: There is large variability in nurse involvement in end-of-life decision-making in the ICU. The most concerning findings were that in some regions, according to physicians, nurses were not involved in EOL decisions and did not initiate the decision-making process. There is a need to develop the collaboration between nurses and physicians. Nurses have valuable contributions for best possible patient-centered decisions and should be respected as important parts of the interdisciplinary team. Tweetable abstract: Wide global differences were found in nurse end of life decision involvement, with low involvement in North and South America and Africa and higher involvement in Europe and Australia/New Zealand. (c) 2024 Elsevier Ltd. All rights reserved.

ObjectiveThe aim of this study is to describe the results of Spanish ICUs in ETHICUS II study.DesignPlanned substudy of patients from ETHICUS II study.Setting12 Spanish ICU.Patients or participantsPatients admitted to Spanish ICU who died or in whom a limitation of life-sustaining treatment (LLST) was decided during a recruitment period of 6 months.InterventionsFollow-up of patients was performed until discharge from the ICU and 2 months after the decision of LLST or death.Main variables of interestDemographic characteristics, clinical profile, type of decision of LLST, time and form in which it was adopted. Patients were classified into 4 categories according to the ETHICUS II study protocol: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, failed cardiopulmonary resuscitation and patients with brain death.ResultsA total of 795 patients were analyzed; 129 patients died after CPR, 129 developed brain death. LLST was decided in 537 patients, 485 died in the ICU, 90.3%. The mean age was 66.19 years ± 14.36, 63.8% of male patients. In 221 (41%) it was decided to withdraw life-sustaining treatments and in 316 (59%) withholding life-sustaining treatments. Nineteen patients (2.38%) had advance living directives.ConclusionsThe predominant clinical profile when LTSV was established was male patients over 65 years with mostly cardiovascular comorbidity.We observed that survival was higher in LLST decisions involving withholding of treatments compared to those in which withdrawal was decided.Spain has played a leading role in both patient and ICU recruitment participating in this worldwide multicenter study.

Introduction: The need for end-of-life care is common in intensive care units (ICUs). Although guidelines exist, little is known about actual endof-life care practices in Hong Kong ICUs. The study aim was to provide a detailed description of these practices. Methods: This prospective, multicentre observational sub-analysis of the Ethicus-2 study explored end-of-life practices in eight participating Hong Kong ICUs. Consecutive adult ICU patients admitted during a 6-month period with lifesustaining treatment (LST) limitation or death were included. Follow-up continued until death or 2 months from the initial decision to limit LST. Results: Of 4922 screened patients, 548 (11.1%) had LST limitation (withholding or withdrawal) or died (failed cardiopulmonary resuscitation/brain death). Life-sustaining treatment limitation occurred in 455 (83.0%) patients: 353 (77.6%) had decisions to withhold LST and 102 (22.4%) had decisions to withdraw LST. Of those who died without LST limitation, 80 (86.0%) had failed cardiopulmonary resuscitation and 13 (14.0%) were declared brain dead. Discussions of LST limitation were initiated by ICU physicians in most (86.2%) cases. Shared decision-making between ICU physicians and families was the predominant model; only 6.0% of patients retained decision-making capacity. Primary medical reasons for LST limitation were unresponsiveness to maximal therapy (49.2%) and multiorgan failure (17.1%). The most important consideration for decision-making was the patient's best interest (81.5%). Conclusion: Life-sustaining treatment limitations are common in Hong Kong ICUs; shared decision making between physicians and families in the patient's best interest is the predominant model. Loss of decision-making capacity is common at the end of life. Patients should be encouraged to communicate end-of-life treatment preferences to family members/ surrogates, or through advance directives.

OBJECTIVE:To evaluate the association between provider religion and religiosity and consensus about end-of-life care and explore if geographical and institutional factors contribute to variability in practice. METHODS:Using a modified Delphi method 22 end-of-life issues consisting of 35 definitions and 46 statements were evaluated in 32 countries in North America, South America, Eastern Europe, Western Europe, Asia, Australia and South Africa. A multidisciplinary, expert group from specialties treating patients at the end-of-life within each participating institution assessed the association between 7 key statements and geography, religion, religiosity and institutional factors likely influencing the development of consensus. RESULTS:Of 3049 participants, 1366 (45%) responded. Mean age of respondents was 45 ± 9 years and 55% were females. Following 2 Delphi rounds, consensus was obtained for 77 (95%) of 81 definitions and statements. There was a significant difference in responses across geographical regions. South African and North American respondents were more likely to encourage patients to write advance directives. Fewer Eastern European and Asian respondents agreed with withdrawing life-sustaining treatments without consent of patients or surrogates. While respondent's religion, years in practice or institution did not affect their agreement, religiosity, physician specialty and responsibility for end-of-life decisions did. CONCLUSIONS:Variability in agreement with key consensus statements about end-of-life care is related primarily to differences among providers, with provider-level variations related to differences in religiosity and specialty. Geography also plays a role in influencing some end-of-life practices. This information may help understanding ethical dilemmas and developing culturally sensitive end-of-life care strategies.

ObjetivoDescribir los resultados obtenidos en UCI españolas en el estudio ETHICUS II.DiseñoSubestudio planificado de pacientes del ETHICUS II.Ámbito12 UCI españolas.Pacientes o participantesPacientes que fallecieron o en los que se decidió una limitación de tratamiento de soporte vital (LTSV) durante un periodo de reclutamiento de 6 meses.IntervencionesSe realizó seguimiento hasta el alta de la UCI y 2 meses tras la decisión de LTSV o fallecimiento.Variables de interés principalesCaracterísticas demográficas, clínicas, tipo de decisión de LTSV. Se clasificaron en 4 categorías: omisión o retirada de tratamientos de soporte, acortar el proceso de morir, resucitación cardiopulmonar ineficaz y muerte cerebral.ResultadosUn total de 12 UCI participaron en el ETHICUS II. Incluyeron 795 pacientes; 129 fallecieron tras realizarse RCP, 129 desarrollaron muerte encefálica. Se decidió LTSV en 537, fallecieron en UCI 485, el 90,3%. La edad media fue 66,19 años±14,36, el 63,8% fueron hombres. En un 41% se decidió retirada de tratamientos de soporte total y en un 59% se procedió a no iniciar medidas. Diecinueve pacientes (2,38%) disponían de documento de voluntades vitales anticipadas.ConclusionesEl perfil clínico predominante cuando se estableció una LTSV fue el de pacientes varones mayores de 65 años con comorbilidad mayoritariamente cardiovascular.La supervivencia fue mayor en las decisiones de LTSV que comprendían la omisión de tratamientos respecto a aquellas en las que se decidió la retirada.España ha ocupado un papel destacado en este estudio multicéntrico de ámbito mundial.

PurposeLimitations of life sustaining therapies (LLST) are frequent in intensive care units (ICUs), but no previous studies have examined end-of-life (EOL) care and LLST in South Africa (SA).Materials and methodsThis study evaluated LLST in SA from the data of a prospective, international, multicentre, observational study (Ethicus-2) and compared practices with countries in the rest of the world.ResultsLLST was relatively common in SA, and withholding was more frequent than withdrawing therapy. However, withdrawing and withholding therapy were less common, while failed CPR was more common, than in many other countries. No patients had an advance directive. Primary reasons for LLST in SA were poor quality of life, multisystem organ failure and patients' unresponsiveness to maximal therapy. Primary considerations for EOL decision-making were good medical practice and patients' best-interest, with the need for an ICU bed only rarely considered.ConclusionsWithholding was more common than withdrawing treatment both in SA and worldwide, although both were significantly less frequent in SA compared with the world average.

Background Healthcare systems often face shortages of certain medical specialists due to lack of interest among medical students. We questioned a common “one solution fits all” approach to this problem which involves monetary incentives to lure students to these specialties. Instead, we used the marketing principle the “consumer knows best” to explore ways of elucidating the reasons and proposing solutions for such shortages. Methods A convenience sample of Israeli 6th-year medical students and interns completed questionnaires to determine why they thought three specialties (geriatrics, anesthesiology, emergency medicine) were unpopular and their ideas on increasing their appeal. Results 119 6th-year students and 84 interns completed questionnaires. Geriatrics was reported having a problematic patient population; not being interesting and challenging; and not considered prestigious by colleagues and the populace. This contrasts with emergency medicine which, although considered prestigious, has difficult working conditions both during and after residency accompanied by much pressure at work. Although, improvements in lifestyle and remuneration were thought by students and interns as possibly making these specialties more attractive, reducing the pressure at work and decreasing on-call obligations were designated by the students/interns as ways to increase emergency medicine’s and anesthesiology’s appeal. Half the students replied that anesthesiology would be more appealing if work was in shifts (< 16 h), while 60% replied so for emergency medicine and only 18% for geriatrics. 90% of students reported that control over lifestyle would make emergency medicine more attractive while 55% and 48% replied positively for anesthesiology and geriatrics, respectively. Conclusions Using the concept “consumer knows best” provided additional insight into the specialty selection process. Students/interns have specialty-specific opinions as to why some specialties are unpopular. Their ideas about attracting more students to these specialties were also specialty-dependent, i.e. “one solution does not fit all”. These observations render problematic a single solution aimed at ameliorating the workforce shortages of multiple specialties. Instead, these results advocate a differential approach wherein the lack of appeal of each unpopular specialty is analyzed individually and the students’/interns’ (the “consumers”) ideas sought resulting in solutions tailored to address each specialty’s lack of attractiveness. Trial Registration None.

BACKGROUND:The future composition of a country's physician workforce depends on medical students' choices of specialties. Students' familiarity with the job market (the healthcare system) they are about to enter and the influence job market conditions have on their choices has not been well explored. This study focuses on whether and how the healthcare system's employment landscape is taken into consideration by medical students and whether this facet adds information about the specialty selection process.METHODS:Fifth-year medical students completed a questionnaire querying their knowledge and perceptions of the national healthcare system, selection criteria for choosing a specialty and a post-residency work position. Data were analyzed with two-tailed Student's t-tests and multivariable regression analysis.RESULTS:The questionnaire was completed by 242 students (49% women). Forty per cent were interested in a specialty where it is 'easy to find work' and 64% in a specialty that 'provides job security'. Only 12% were attracted to specialties with empty positions due to a workforce shortage. A high salary was considered an important selection criterion by 45% of students, who were also not deterred by specialties with surplus workforce, especially, if accompanied by high salaries or controllable lifestyles. Only 17% thought it would be easy to find a residency in any hospital in the specialty they chose, reflecting the low rate (3%) of positive responses to the statement that 'there are sufficient residency positions in all specialties'.CONCLUSIONS:This study demonstrated the utility of querying medical students about their market awareness when investigating the specialty selection process. Students' poor rating of selection criteria, such as specialties with ease in finding jobs because they are suffering workforce shortages and have empty positions, provide insights and concerns for healthcare leaders. It should aid them in approaching the challenge of attracting students to specialties with workforce shortfalls.KEY MESSAGESThis study demonstrated the feasibility and potential value of adding queries about market awareness when investigating the medical student specialty selection process.Medical students were more interested in a specialty that provides job security than one where it is easy to find work.It could be useful for the healthcare leadership and medical educators in all countries to learn what medical students know about their national healthcare system and whether they need to add more healthcare delivery and system subjects to their curricula.

Abstract Purpose explore global ICU nurse involvement in end of life decisions, ETHICUS-2 prospective multinational, observational study was performed. Methods This is a secondary analysis of data obtained from the ETHICUS-2 study. Patients were followed until ICU discharge, death, or 2 months from the first decision to limit life-prolonging therapies. Data were collected by an ICU clinician recording end of life decisions typically at the time of first limitation. Nursing related questions included: were withholding or withdrawing treatment discussed with nurses? Who initiated the end of life discussion? Was a nurse involved in making the end of life decision? Was there agreement between physicians and nurses. Global regions were compared related to these four questions. Results A significant difference was found between regions, (p< .001) with Northern Europe and Australia/New Zealand having the most discussion with nurses and Latin America, Africa, Asia and North America the least. The percentages of nurses who were involved end of life decision ranging between 3-44%, the differences were statistically significant. Agreement between physicians and nurses related to decisions resulted in wide range of responses (27-86%) (p < .001). The percentages of EOL decisions in which agreement between physicians and nurses was not applicable included a wide range of responses from 0-41% Conclusion A large variability in nurse involvement in end of life care in the ICU was found. Perhaps due to perception of physicians and nurses view of themselves. Varying levels of expertise and experience of clinicians.

Editor—We read with interest the excellent meta-analysis on pre-emptive analgesia1 that was published recently in the British Journal of Anaesthesia. Surprisingly, this study included data from a study from Scott Reuben (reference 19 in Xuan and colleagues1), formerly of the Baystate Medical Center (Springfield, MA, USA). This author was discovered to have fabricated research data in multiple scientific articles, resulting in 25 retractions,2 and a jail sentence for healthcare fraud.3 The study cited has not been retracted.

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-sustaining therapy were analysed regarding changes in end-of-life practices and patient/physician religious affiliations. Frequencies, 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 physicians (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 commonly 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.

BACKGROUND: Prolonging life in the ICU increasingly is possible, so decisions to limit life-sustaining therapies frequently are made and communicated to patients and families or surrogates. Little is known about worldwide communication practices and influencing factors. RESEARCH QUESTION: Are there regional differences in end-of-life communication practices in ICUs worldwide? STUDY DESIGN AND METHODS: This analysis of data from a prospective, international study specifically addressed end-of-life communications in consecutive patients who died or had limitation of life-sustaining therapy over 6 months in 199 ICUs in 36 countries, grouped regionally. End-of-life decisions were recorded for each patient and ethical practice was assessed retrospectively for each ICU using a 12-point questionnaire developed previously. RESULTS: Of 87,951 patients admitted, 12,850 died or experienced a limitation of therapy (14.6%). Of these, 1,199 patients (9.3%) were known to have an advance directive, and wishes were elicited from 6,456 patients (50.2%). Limitations of life-sustaining therapy were implemented for 10,401 patients (80.9%), 1,970 (19.1%) of whom had mental capacity at the time, and were discussed with 1,507 patients (14.5%) and 8,461 families (81.3%). Where no discussions with patients occurred (n = 8,710), this primarily was because of a lack of mental capacity in 8,114 patients (93.2%), and where none occurred with families (n = 1,622), this primarily was because of unavailability (n = 720 [44.4%]). Regional variation was noted for all end points. In generalized estimating equation (GEE) analyses, the odds for discussions with the patient or family increased by 30% (OR, 1.30; 95% CI, 1.18-1.44; P < .001) for every one-point increase in the Ethical Practice Score and by 92% (OR, 1.92; 95% CI, 1.28-2.89; P = .002) in the presence of an advance directive. INTERPRETATION: End-of-life communication with patients and families or surrogates varies markedly in different global regions. GEE analysis supports the hypothesis that communication may increase with ethical practice and an advance directive. Greater effort is needed to align treatment with patients' wishes.

Abstract Background Limitations of life-sustaining interventions in intensive care units (ICUs) exhibit substantial changes over time, and large, contemporary variation across world regions. We sought to determine whether a weighted end-of-life practice score can explain a large, contemporary, worldwide variation in limitation decisions. Methods The 2015–2016 (Ethicus-2) vs. 1999–2000 (Ethicus-1) comparison study was a two-period, prospective observational study assessing the frequency of limitation decisions in 4952 patients from 22 European ICUs. The worldwide Ethicus-2 study was a single-period prospective observational study assessing the frequency of limitation decisions in 12,200 patients from 199 ICUs situated in 8 world regions. Binary end-of-life practice variable data (1 = presence; 0 = absence) were collected post hoc (comparison study, 22/22 ICUs, n = 4592; worldwide study, 186/199 ICUs, n = 11,574) for family meetings, daily deliberation for appropriate level of care, end-of-life discussions during weekly meetings, written triggers for limitations, written ICU end-of-life guidelines and protocols, palliative care and ethics consultations, ICU-staff taking communication or bioethics courses, and national end-of-life guidelines and legislation. Regarding the comparison study, generalized estimating equations (GEE) analysis was used to determine associations between the 12 end-of-life practice variables and treatment limitations. The weighted end-of-life practice score was then calculated using GEE-derived coefficients of the end-of-life practice variables. Subsequently, the weighted end-of-life practice score was validated in GEE analysis using the worldwide study dataset. Results In comparison study GEE analyses, end-of-life discussions during weekly meetings [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.30–0.99], end-of-life guidelines [OR 0.52, (0.31–0.87)] and protocols [OR 15.08, (3.88–58.59)], palliative care consultations [OR 2.63, (1.23–5.60)] and end-of-life legislation [OR 3.24, 1.60–6.55)] were significantly associated with limitation decisions (all P < 0.05). In worldwide GEE analyses, the weighted end-of-life practice score was significantly associated with limitation decisions [OR 1.12 (1.03–1.22); P = 0.008]. Conclusions Comparison study-derived, weighted end-of-life practice score partly explained the worldwide study’s variation in treatment limitations. The most important components of the weighted end-of-life practice score were ICU end-of-life protocols, palliative care consultations, and country end-of-life legislation.