Exclusion of patients who died within 48 hours after admission to the ICU is a limitation of our study. We thought that, in this group of patients, dealing with end-of-life dilemmas is unusual, because, in most cases, important EPZ-5676 aspects of the previous medical history are unknown, and prognosis is uncertain.Another limitation is that the validity of the questionnaire may be challenged, because it was not tested before the study. The questionnaire’s structure was based on a literature survey of factors that influence end-of-life practice. Also, we did not evaluate the impact of patient race, ethnicity, religion, and socioeconomic status on end-of-life decisions. Yet, a large variation of these parameters does not exist in the Greek ICU population.

Finally, we did not investigate the possible association between physician characteristics (age, medical specialty, years of clinical experience) and his or her willingness to withhold or to withdraw life-sustaining therapies.ConclusionsThis prospective multicenter study showed that limitation of life-sustaining treatment is a common phenomenon in the Greek ICUs studied. However, in a large majority of cases, it is equivalent to the withholding of CPR alone. Withholding of other therapies besides CPR is not routine, and withdrawal of support is infrequent. The main factor guiding the decision to limit therapy is unresponsiveness to treatment already offered. Economic cost and lack of ICU beds seem to play no role. As in other European countries, the paternalistic model predominates in decision making.

By recording current medical practice and its motivations in end-of-life situations, our study helps to translate moral principles into legal and scientific guidelines. Such guidelines can use recent international recommendations as a baseline reference and adapt them to our local particularities.Key messages? Limitation of life-sustaining treatment is a common phenomenon in the Greek ICUs studied. However, in most cases, it involves the withholding of CPR only.? Withholding of other therapies besides CPR and withdrawal of support are infrequent.? Unresponsiveness to treatment already offered is the main factor influencing the physician’s decision to limit therapy.? Medical paternalism prevails in the decision-making process.

? Death does not always ensue shortly after withholding or withdrawal of treatment; patients whose death is not immediately imminent should be transferred to suitable hospices.AbbreviationsAIDS: acquired immunodeficiency syndrome; APACHE: Acute Brefeldin_A Physiology and Chronic Health Evaluation; CPR: cardiopulmonary resuscitation; DNR: do not resuscitate; GCS: Glascow Coma Scale; HIV: human immunodeficiency virus; ICU: intensive care unit; NYHA: New York Heart Association; SD: standard deviation.Competing interestsThe authors declare that they have no competing interests.