To access, purchase, authenticate, or subscribe to the full-text of this article, please visit this link: http://dx.doi.org/10.1007/s00134-016-4347-y Byline: Jason Phua (1), Gavin M. Joynt (2), Masaji Nishimura (3), Yiyun Deng (4), Sheila Nainan Myatra (5), Yiong Huak Chan (6), Nguyen Gia Binh (7), Cheng Cheng Tan (8), Mohammad Omar Faruq (9), Yaseen M. Arabi (10), Bambang Wahjuprajitno (11), Shih-Feng Liu (12,13), Seyed Mohammad Reza Hashemian (14), Waqar Kashif (15), Dusit Staworn (16), Jose Emmanuel Palo (17), Younsuck Koh (18) Keywords: End-of-life care; Critical care; Physicians; Families; Legal; Economics Abstract: Purpose To compare the attitudes of physicians towards withholding and withdrawing life-sustaining treatments in intensive care units (ICUs) in low-middle-income Asian countries and regions with those in high-income ones, and to explore differences in the role of families and surrogates, legal risks, and financial considerations between these countries and regions. Methods Questionnaire study conducted in May--December 2012 on 847 physicians from 255 ICUs in 10 low-middle-income countries and regions according to the World Bank's classification, and 618 physicians from 211 ICUs in six high-income countries and regions. Results After we accounted for personal, ICU, and hospital characteristics on multivariable analyses using generalised linear mixed models, physicians from low-middle-income countries and regions were less likely to limit cardiopulmonary resuscitation, mechanical ventilation, vasopressors and inotropes, tracheostomy and haemodialysis than those from high-income countries and regions. They were more likely to involve families in end-of-life care discussions and to perceive legal risks with limitation of life-sustaining treatments and do-not-resuscitate orders. Nonetheless, they were also more likely to accede to families' requests to withdraw life-sustaining treatments in a patient with an otherwise reasonable chance of survival on financial grounds in a case scenario (adjusted odds ratio 5.05, 95 % confidence interval 2.69--9.51, P Conclusions Significant differences in ICU physicians' self-reported practice of limiting life-sustaining treatments, the role of families and surrogates, perception of legal risks and financial considerations exist between low-middle-income and high-income Asian countries and regions. Author Affiliation: (1) Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Singapore, Singapore (2) Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (3) Emergency and Critical Care Medicine, University of Tokushima Graduate School, Tokushima, Japan (4) Intensive Care Unit, West China Hospital of Sichuan University, Chengdu, China (5) Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India (6) Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (7) Intensive Care Department, Bach Mai Hospital, Hanoi, Vietnam (8) Department of Anaesthesia and Intensive Care, Sultanah Aminah Hospital, Johor Bahru, Malaysia (9) Department of Critical Care Medicine, BIRDEM General Hospital, Ibrahim Medical College, Dhaka, Bangladesh (10) King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (11) Department of Anesthesiology and Reanimation, Faculty of Medicine, University of Airlangga, Dr. Soetomo General Hospital, Surabaya, Indonesia (12) Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (13) Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (14) Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (15) Section of Nephrology, Pulmonary and Critical Care, Department of Medicine, Aga Khan University and Hospital, Karachi, Pakistan (16) Phramongkutklao Hospital, Bangkok, Thailand (17) The Medical City, Pasig City, Philippines (18) Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap Dong Songpa Ku, Seoul, 138-736, South Korea (19) c/o Jason Phua, 1E Kent Ridge Road, Singapore, 119228, Singapore Article History: Registration Date: 30/03/2016 Received Date: 11/12/2015 Accepted Date: 30/03/2016 Online Date: 12/04/2016 Article note: Take-home message: As opposed to high-income countries and regions, physicians in low-middle-income Asian countries and regions often make end-of-life care decisions predominantly based on perceived families' demands and financial constraints rather than patients' wishes and medical conditions, while resources are often spent on prolonging deaths rather than saving lives. A more coherent, humane, cost-effective and yet culturally sensitive approach to dying patients is needed in these countries and regions. On behalf of the ACME Study Investigators and the Asian Critical Care Clinical Trials Group. The members of the ACME Study Investigators and the Asian Critical Care Clinical Trials Group are listed under Acknowledgments. Electronic supplementary material The online version of this article (doi: 10.1007/s00134-016-4347-y) contains supplementary material, which is available to authorized users. An erratum to this article can be found at http://dx.doi.org/10.1007/s00134-016-4365-9.