Lancet Publishes Largest Global Study, Led by Hadassah Medical Organization, On Disparities in End-of-Life Practices

Friday, August 6, 2021

Alix Friedman

NEW YORK, NY: August 6, 2021 – A study led by physicians from Jerusalem’s Hadassah Medical Organization and published yesterday in The Lancet Respiratory Medicine reveals considerable disparities in the way physicians approach end-of-life decisions in conservative and liberal regions of the world. The study, the largest ever done on end-of-life practices in intensive care units worldwide, has critical implications for doctors who treat patients coming from different regions of the world and doctors who travel to other parts of the world for advanced training.  

The research, which was led by Hadassah’s Professor Charles Sprung, MD, Director Emeritus of Hadassah’s General Intensive Care Unit and a medical ethicist and lawyer, and Alexander Avidan, MD, Director of Hadassah’s Unit for Medical Informatics and Data Management, Department of Anesthesiology, involved 12,850 patients and 199 intensive care units in 36 countries in North America, Latin America, Africa, Asia, Australia and New Zealand, Central Europe, Northern Europe and Southern Europe.

The study, “Variations in End-of-Life Practices in Intensive Care Units Worldwide,” examined data on four types of end-of-life interventions: withholding life-sustaining therapies, i.e., not giving additional treatments to those a patient is already receiving; withdrawing life-sustaining therapies, i.e., actively removing therapies already being given to a patient; actively shortening the dying process; and CPR. Most ICU deaths are preceded by decisions to withhold or withdraw life-sustaining treatments.

This study sought to understand how these decisions are affected by local/regional factors, such as cultural, geographic, economic and legal differences and differences involving religious and ethical sensitivities and practices.

Among the main conclusions:

  • The most common limitation in the study population was withholding life-sustaining therapy followed by withdrawing life-sustaining therapy, while active shortening of the dying process was hardly ever used (0.5%).
  • As opposed to all other regions, Northern Europe and the joint region of Australia and New Zealand reported more incidences of withdrawing life-sustaining therapy than withholding it.
  • The lowest rates of withdrawal were in Latin America and Africa.
  • Treatment limitations are far more common in Northern Europe, Australia and New Zealand, and North America than in Africa, Latin America and Southern Europe.
  • Treatment limitations are more common in regions with countries that have higher gross national incomes and end-of-life legislation.
  • There was an unexpectedly high hospital survival rate (20%) after treatment limitations, with a 28% survival rate after withholding them and a 12% survival rate after withdrawing them.

Patients were studied from admission until death, or for two months from the first limitation decision.

The categories of end-of-life decisions were based on Dr. Sprung’s 2003 JAMA paper, “End-of-Life Practices in European Intensive Care Units: The Ethics Study.” They are CPR, brain death, withholding end-of-life interventions, withdrawing end-of-life interventions and active shortening of the dying process (SDP).

Said Dr. Sprung: “Some of the contrasts are significant. You have Belgium and the Netherlands, where active euthanasia is legal, and here in Israel, where it is illegal to turn off ventilators. We thought it would be fascinating to look further into these differences with the hope that we can improve end-of-life care. There are some regions that act more quickly while others, like Africa, Latin America and Southern Europe, are slower to make those decisions.”

Said Dr. Avidan: “In the West, there’s a greater attempt to understand the wishes of the patient. In other regions, where they are perhaps more conservative or religious, the approach is more paternalistic. As doctors move from one place to another, it’s important for them to understand the differing views. There’s no best practice. My personal approach is quite conservative: active intervention by withdrawing, deciding that a patient should die, is a slippery slope. Passive intervention, by withholding, is another matter."


Hadassah, The Women’s Zionist Organization of America, Inc. (HWZOA), is the largest Jewish women’s organization in the United States. With nearly 300,000 members, Associates and supporters, HWZOA brings women together to effect change and advocate on such critical issues as ensuring the security of Israel, combating antisemitism and promoting women’s health. Through the two hospitals of the Hadassah Medical Organization (HMO) in Jerusalem, HWZOA helps support both exemplary care for more than one million people every year and world-renowned medical research. HMO serves without regard to race, religion or nationality and earned a Nobel Peace Prize nomination in 2005 for building bridges to peace through medicine. Additionally, HWZOA supports several Youth Aliyah villages that set at-risk children in Israel on the path to a successful future. For more information, visit or follow Hadassah on Facebook, Instagram, LinkedIn and Twitter.