Variation in Decisions to Forgo Life-Sustaining Therapies in US ICUs

doi:10.1378/chest.13-2529

Chest

Volume 146, Issue 3, September 2014, Pages 573-582

https://doi.org/10.1378/chest.13-2529 Get rights and content

BACKGROUND

The magnitude and implication of variation in end-of-life decision-making among ICUs in the United States is unknown.

METHODS

We reviewed data on decisions to forgo life-sustaining therapy (DFLSTs) in 269,002 patients admitted to 153 ICUs in the United States between 2001 and 2009. We used fixed-effects logistic regression to create a multivariable model for DFLST and then calculated adjusted rates of DFLST for each ICU.

RESULTS

Patient factors associated with increased odds of DFLST included advanced age, female sex, white race, and poor baseline functional status (all P< .001). However, associations with several of these factors varied among ICUs (eg, black race had an OR for DFLST from 0.18 to 2.55 across ICUs). The ICU staffing model was also found to be associated with DFLST, with an open ICU staffing model associated with an increased odds of a DFLST (OR= 1.19). The predicted probability of DFLST varied approximately sixfold among ICUs after adjustment for the fixed patient and ICU effects and was directly correlated with the standardized mortality ratios of ICUs (r= 0.53, 0.41–0.68).

CONCLUSION

Although patient factors explain much of the variability in DFLST practices, significant effects of ICU culture and practice influence end-of-life decision-making. The observation that an ICU's risk-adjusted propensity to withdraw life support is directly associated with its standardized mortality ratio suggests problems with using the latter as a quality measure.

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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12 UCI españolas.
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Se realizó seguimiento hasta el alta de la UCI y 2 meses tras la decisión de LTSV o fallecimiento.
Características demográficas, clínicas, tipo de decisión de LTSV. Se clasificaron en 4 categorías: omisión o retirada de tratamientos de soporte, acortar el proceso de morir, resucitación cardiopulmonar ineficaz y muerte cerebral.
Un total de 12 UCI participaron en el ETHICUS II. Incluyeron 795 pacientes; 129 fallecieron tras realizarse RCP, 129 desarrollaron muerte encefálica. Se decidió LTSV en 537, fallecieron en UCI 485, el 90,3%. La edad media fue 66,19 años ± 14,36, el 63,8% fueron hombres. En un 41% se decidió retirada de tratamientos de soporte total y en un 59% se procedió a no iniciar medidas. Diecinueve pacientes (2,38%) disponían de documento de voluntades vitales anticipadas.
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España ha ocupado un papel destacado en este estudio multicéntrico de ámbito mundial.
The aim of this study is to describe the results of Spanish ICUs in ETHICUS II study.
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Patients admitted to Spanish ICU who died or in whom a limitation of life-sustaining treatment (LLST) was decided during a recruitment period of 6 months.
Follow-up of patients was performed until discharge from the ICU and 2 months after the decision of LLST or death.
Demographic characteristics, clinical profile, type of decision of LLST, time and form in which it was adopted. Patients were classified into 4 categories according to the ETHICUS II study protocol: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, failed cardiopulmonary resuscitation and patients with brain death.
A total of 795 patients were analyzed; 129 patients died after CPR, 129 developed brain death. LLST was decided in 537 patients, 485 died in the ICU, 90.3%. The mean age was 66.19 years ± 14.36, 63.8% of male patients. In 221 (41%) it was decided to withdraw life-sustaining treatments and in 316(59%) withholding life-sustaining treatments. Nineteen patients (2.38%) had advance living directives.
The predominant clinical profile when LTSV was established was male patients over 65 years with mostly cardiovascular comorbidity.
We observed that survival was higher in LLST decisions involving withholding of treatments compared to those in which withdrawal was decided.
Spain has played a leading role in both patient and ICU recruitment participating in this worldwide multicenter study.
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Old patients have higher risk of death during the ICU stay, in the hospital and after discharge. When they survive, they may suffer from long-term sequel, including loss of functional autonomy and poor quality of life, and they often represent a heavy burden for the caregivers. All these factors contribute to more frequent decisions to limit and stop treatment (LST) in old patients compared to younger patients. The work-up of this decision has an impact on the ICU team and the family members. Collegiality, timing, transparency, objectivity are keys to prevent conflict, complicated griefs, and allow for the grieving process. This review explores limitation of life-sustaining treatments in the ICU: determinants, timing, impact. The shared decision-making model between the patient, his family and the healthcare team should be promoted. In a situation of prognostic uncertainty, the doubt must benefit the patient and an admission decision must be taken. After a few days, additional information could be collected and the evolution under treatment evaluated. During a family conference, it is decided collectively whether or not to continue active treatments. It is the concept of time-limited trial that applies particularly well to elderly patients.
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Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients’ outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization.
End of life decisions in immunocompromised patients with acute respiratory failure
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To identify patient, disease and organizational factors associated with decisions to forgo life-sustaining therapies (DFLSTs) in critically ill immunocompromised patients admitted to the intensive care unit (ICU) for acute respiratory failure.
We performed a secondary analysis of the international EFRAIM prospective study, which enrolled 1611 immunocompromised patients with acute respiratory failure admitted to 68 ICUs in 16 countries between October 2015 and June 2016. Multivariate logistic analysis was performed to identify independent predictors of DFLSTs.
The main causes of immunosuppression were hematological malignancies (50%) and solid tumor (38%). Patients had a median age of 63 yo (54–71). A pulmonologist was involved in the patient management in 38% of cases. DFLSTs had been implemented in 28% of the patients. The following variables were independently associated with DFLSTs: 1) patient-related: older age (OR 1.02 per one year increase, 95% confidence interval(CI) 1.01–1.03,P < 0.001), poor performance status (OR 2.79, 95% CI 1.98–3.93, P < 0.001); 2) disease-related: shock (OR 2.00, 95% CI 1.45–2.75, P < 0.001), liver failure (OR 1.59, 95% CI 1.14–2.21, P = 0.006), invasive mechanical ventilation (OR 1.79, 95% CI 1.31–2.46, P < 0.001); 3) organizational: having a pulmonologist involved in patient management (OR 1.85, 95% CI 1.36–2.52, P < 0.001), and the presence of a critical care outreach services (OR 1.63, 95% CI 1.11–2.38, P = 0.012).
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2022, American Journal of Surgery
Citation 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
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Of 942,914 identified, 20,052 (2.1%) died. Of those who died, WLST occurred in 29.9%. The adjusted odds of WLST were lower in Blacks (OR 0.48, 95% CI 0.41–0.57) and Hispanics (OR 0.71, 95% CI 0.57–0.89) than Whites. The predicted probability of WLST in Black patients remained lower than Whites at 30 days.
Among non-head injured dying patients, Blacks and Hispanics are less likely to utilize WLST than Whites. Further investigation into the socio-cultural norms and institutional distrust influencing these differences is imperative.

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FUNDING/SUPPORT: Dr Quill was supported by National Institutes of Health T32HL098054 Training in Critical Care Health Policy Research.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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Chest

Original Research: Critical CareVariation in Decisions to Forgo Life-Sustaining Therapies in US ICUs

BACKGROUND

METHODS

RESULTS

CONCLUSION

Section snippets

Data Source

Patients and Outcome Variable

Results

Discussion

Conclusions

Acknowledgments

Am J Med

Chest

J Am Med Dir Assoc

Crit Care Clin

Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study

Crit Care Med

A national survey of end-of-life care for critically ill patients

Am J Respir Crit Care Med

French PROTOCETIC Group. French intensivists do not apply American recommendations regarding decisions to forgo life-sustaining therapy

Crit Care Med

American College of Critical Care Medicine Task Force 2004-2005, Society of Critical Care Medicine. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005

Crit Care Med

Advance directives and outcomes of surrogate decision making before death

N Engl J Med

Delirium in the intensive care unit

Crit Care

A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT)

JAMA

Variation in the rates of do not resuscitate orders after major trauma and the impact of intensive care unit environment

J Trauma

SAPS 3 investigators. End-of-life practices in 282 intensive care units: data from the SAPS 3 database

Intensive Care Med

The epidemiology of intensive care unit readmissions in the United States

Am J Respir Crit Care Med

Bloomberg Businessweek website

DELAY-ED Study Group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit

Crit Care Med

Morbid obesity is an independent determinant of death among surgical critically ill patients

Crit Care Med

Original Research: Critical Care
Variation in Decisions to Forgo Life-Sustaining Therapies in US ICUs