Chest
Original Research: Critical CareVariation in Decisions to Forgo Life-Sustaining Therapies in US ICUs
Section snippets
Data Source
Using the Project IMPACT database (Cerner Corp), we performed a retrospective cohort study on patients admitted to ICUs between 2001 and 2009. Project IMPACT is a voluntary, fee-based ICU clinical information system that is commonly used in critical care outcomes research.12, 13, 14, 15 Each enrolled ICU employs a staff member who is trained to use a standardized web-based instrument to collect data on individual patients, processes of care, and ICU characteristics.
Patients and Outcome Variable
To preserve independence
Results
The full dataset contained 400,128 patients admitted to 196 ICUs between April 1, 2001 and February 29, 2009. Exclusions are shown in e-Figure 1. The final analytic dataset included 270,442 patients admitted to 153 ICUs in 105 hospitals in the United States with no limitations on care in place at the time of ICU admission.
Among the 269,002 patients (99.5%) with information on DFLST at discharge or death, 31,408 (11.7%) had a DFLST made in the ICU (Fig 1). The sample had considerable diversity
Discussion
Making decisions to limit life-sustaining therapies in an ICU is a complex process that may be influenced by the characteristics of the patients,7, 8, 9, 10, 11 family members,19 providers,20 and institutions in which the decisions are made.21 Prior studies have made clear that making such decisions is strongly associated with patients' clinical and demographic characteristics.3, 7, 9, 10, 11, 22, 23, 24, 25, 26, 27, 28, 29 These relationships are unlikely to be directly causal. Rather, older
Conclusions
By suggesting that substantial ICU-level variability in DFLST rates persist after accounting for patient characteristics, this study highlights opportunities for improving the patient-centeredness of end-of-life decision-making across the United States. Specifically, understanding differences in how physicians reach and convey prognostic judgments, and how ICU organizational factors influence DFLSTs, may enable targeted interventions to improve the quality of end-of-life care in all ICUs.
Acknowledgments
Author contributions: C. M. Q. takes responsibility for the integrity of the work as a whole. C. M. Q. contributed to the concept and design of the study, data acquisition, analysis, and interpretation, and drafting and revision of the manuscript; S. J. R. and M. O. H. contributed to the design of the study, data analysis, and interpretation and revision of the manuscript; and S. D. H. contributed to the concept and design of the study, data acquisition, analysis, and interpretation, and
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2023, Bulletin de l'Academie Nationale de MedecineThe TRIBE model: How socioemotional processes fuel end-of-life treatment in the United States
2023, Social Science and MedicineEnd of life decisions in immunocompromised patients with acute respiratory failure
2022, Journal of Critical CareRacial and ethnic disparities in withdrawal of life-sustaining treatment after non-head injury trauma
2022, American Journal of SurgeryCitation Excerpt :As more than 1 in 5 critically ill patients die in the intensive care unit (ICU) despite aggressive life-sustaining therapies, the need to explore variation in EOL care is imperative.8,9 Significant racial and ethnic disparities in EOL care among the critically ill are well described.9–12 However, a growing body of evidence suggests that decisions regarding EOL care between medical and surgical patients can be vastly different.13–15
FUNDING/SUPPORT: Dr Quill was supported by National Institutes of Health T32HL098054 Training in Critical Care Health Policy Research.
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