The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research.

1st Department of Intensive Care Medicine National and Kapodistrian University of Athens Medical School Evaggelismos General Hospital Athens Greece

2nd Department of Anaesthesiology and Intensive Care Medicine University Hospital Brno Brno Czechia

Ahmedabad Shaibya Comprehensive Care Clinic Ahmedabad India

Anesthesia and Intensive Care Ospedale Uboldo Cernusco sul Naviglio Milan Italy

Biomedical Sciences Department Humanitas University Milan Italy

Bruyere Research Institute Ottawa Canada

Centrum Voor Intensive Care Medisch Centrum Leeuwarden Leeuwarden The Netherlands

CLINURSID Research Group University of Santiago de Compostela Santiago de Compostela Spain

Critical Care and Respiratory Medicine University Health Network Toronto General Research Institute Toronto Canada

Curtin School of Nursing Curtin University Perth Australia

Department of Anaesthesia and Intensive Care IRCCS Humanitas Research Hospital Milan Italy

Department of Anaesthesiology and Intensive Care Medicine Charité Universitätsmedizin Berlin Freie Universität Berlin and Humboldt Universität zu Berlin Berlin Germany

Department of Anaesthesiology and Intensive Care Medicine University Hospital Brno and Faculty of Medicine Masaryk University Brno Czechia

Department of Anesthesia Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston MA USA

Department of Anesthesia Intensive Care and Emergency San Giovanni Bosco Hospital Turin Italy

Department of Anesthesiology Critical Care Emergency Medicine and Pain Therapy Konstanz Hospital Constance Germany

Department of Anesthesiology Critical Care Medicine and Pain Hadassah Medical Center Faculty of Medicine Hebrew University of Jerusalem Jerusalem Israel

Department of Critical Care AmsterdamUMC Location VUmc Amsterdam The Netherlands

Department of Critical Care King's College Hospital NHS Foundation Trust London UK

Department of Intensive Care Adults Erasmus MC University Medical Centre Rotterdam Rotterdam The Netherlands

Department of Intensive Care Medicine Ghent University Hospital Ghent Belgium

Department of Intensive Care Medicine University Clinic Hospital of Santiago de Compostela Santiago de Compostela Spain

Department of Intensive Care Medicine University Medical Center Utrecht Utrecht University Utrecht The Netherlands

Department of Intensive Care Radboud University Medical Center Nijmegen The Netherlands

Department of Medicine Divisions of Critical Care and Pulmonology Charlotte Maxeke Johannesburg Academic Hospital Johannesburg South Africa

Department of Medicine University of Ottawa Ottawa Canada

Department of Medicine University of Udine Udine Italy

Department of Neuroscience Reproductive Science and Dentistry University of Naples Naples Italy

Department of Nursing Zhongshan Hospital Fudan University Shanghai China

Department of Paediatric Anaesthesiology and Intensive Care Medicine University Hospital Brno and Faculty of Medicine Masaryk University Brno Czechia

Department of Palliative Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague Prague Czechia

Department of Palliative Medicine University Hospital Bonn Bonn Germany

Department of Pathophysiology and Transplantation Università degli Studi di Milano Milan Italy

Department of Simulation Medicine Faculty of Medicine Masaryk University Brno Czechia

Division of Pulmonary and Critical Care Medicine Duke University Durham NC USA

Faculdade de Ciências da Saúde Universidade da Beira Interior Covilhã Portugal

Faculdade de Ciências Médicas de Lisboa Nova Medical School Centro Clínico Académico de Lisboa Lisbon Portugal

Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa

Faculty of Medicine and Health Science Ghent University Ghent Belgium

Faculty of Medicine School of Nursing Hebrew University Jerusalem Israel

Famiréa Research Group APHP Nord Saint Louis Hospital Intensive Care Unit Paris France

Gelderse Vallei Hospital Ede The Netherlands

Hospital Arnau de Vilanova Lliria Valencia Spain

Hospital de São José Unidade Local de Saúde São José Lisbon Portugal

Imperial Healthcare NHS Trust Imperial College London UK

Institute of Medical Sciences Interdepartmental Division of Critical Care Medicine University of Toronto Toronto Canada

Intensive Care Department King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center Ministry of National Guard Health Affairs Riyadh Saudi Arabia

Intensive Care Glasgow Royal Infirmary Glasgow UK

Interdepartmental Division Critical Care Medicine Toronto Western Hospital University Health Network University of Toronto Toronto Canada

King's College London London UK

Médecine Intensive et Réanimation APHP Saint Louis Hospital Paris France

Memorial Hospital Weill Cornell Medical College New York NY USA

National Institute for Health and Care Research London UK

Royal Devon University NHS Foundation Trust Exeter UK

S C Anesthesia and Intensive Care Legnano Hospital ASST Ovest Milanese Milan Italy

Sabar Health Netanya Israel

Sapienza University of Rome A O U Sant'Andrea Rome Italy

School of Nursing and Midwifery Faculty of Health University of Plymouth Plymouth UK

School of Nursing and Midwifery University of Birmingham Birmingham UK

School of Nursing University of California San Francisco San Francisco CA USA

Simulation Life Support and Intensive Care Research Unit of Santiago de Compostela Santiago de Compostela Spain

Universidad Católica de Valencia San Vicente Mártir Valencia Spain

Université Paris Cité Paris France

University of Glasgow Glasgow UK

University of Hertfordshire East and North Hertfordshire NHS Trust Hatfield UK

Wolfson Palliative Care Research Centre Hull York Medical School University of Hull Hull UK

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