Log in | Register

Respective impact of no escalation of treatment, withholding and withdrawal of life-sustaining treatment on ICU patients’ prognosis: a multicenter study of the Outcomerea Research Group

Alexandre Lautrette| Maïté Garrouste-Orgeas| Pierre-Marie Bertrand| Dany Goldgran-Toledano| Samir Jamali| Virginie Laurent| Laurent Argaud| Carole Schwebel| Bruno Mourvillier| Michaël Darmon| Stéphane Ruckly| Anne-Sylvie Dumenil| Virginie Lemiale| Bertrand Souweine| Jean-François Timsit
Original
Volume 41, Issue 10 / October , 2015

Pages 1763 - 1772

Abstract

Purpose

To assess the prevalence of decisions to forgo life-sustaining treatment (DFLST), the patients characteristics, and to estimate the impact of DFLST stages on mortality.

Methods

Observational study of a prospective database between 2005 and 2012 from 13 ICUs. DFLST were defined as follows: no escalation of treatment (stage 1), not to start or escalate treatment even if such treatment is considered in the future; withholding (stage 2), not to start or escalate necessary treatment; withdrawal (stage 3), to stop necessary treatment. The impact of daily DFLST stage on day-30 hospital mortality was tested with a discrete-time Cox’s model and adjusted for admission severity and daily SOFA score.

Results

Of 10,080 patients, 1290 (13 %) made DFLST. The highest DFLST stage during the ICU stay was no escalation of treatment in 339 (26 %) patients, withholding in 502 (39 %) patients, and withdrawal in 449 (35 %) patients. Older patients, patients with at least one chronic disease, and patients with greater ICU severity were significantly more numerous in the DFLST group. Day-30 mortality was 13 % for non-DFLST patients, 35 % for no escalation of treatment, 75 % for withholding, 93 % for withdrawal. After adjustment, an increase in day-30 mortality was associated with withholding and withdrawal (hazard ratio 95 % CI 5.93 [4.95–7.12] and 20.05 [15.58–25.79], P < 0.0001), but not with no escalation of treatment (HR 1.14 [0.91–1.44], P = 0.25).

Conclusions

DFLST were made in 13 % of ICU patients. Withholding, withdrawal, older age, more comorbidities, and higher severity of illness were associated with higher mortality. No escalation of treatment was not associated with increased mortality.

Keywords

References

  1. Eidelman LA, Jakobson DJ, Pizov R, Geber D, Leibovitz L, Sprung CL (1998) Foregoing life-sustaining treatment in an Israeli ICU. Intensive Care Med 24:162–166
  2. Prendergast TJ, Claessens MT, Luce JM (1998) A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med 158:1163–1167
    • View reference on publisher's website
    • View reference on PubMed
  3. Quill CM, Ratcliffe SJ, Harhay MO, Halpern SD (2014) Variation in decisions to forgo life-sustaining therapies in US ICUs. Chest 146:573–582
    • View reference on publisher's website
    • View reference on PubMed
  4. Esteban A, Gordo F, Solsona JF, Alia I, Caballero J, Bouza C, Alcala-Zamora J, Cook DJ, Sanchez JM, Abizanda R, Miro G, Fernandez Del Cabo MJ, de Miguel E, Santos JA, Balerdi B (2001) Withdrawing and withholding life support in the intensive care unit: a Spanish prospective multi-centre observational study. Intensive Care Med 27:1744–1749
  5. Hoel H, Skjaker SA, Haagensen R, Stavem K (2014) Decisions to withhold or withdraw life-sustaining treatment in a Norwegian intensive care unit. Acta Anaesthesiol Scand 58:329–336
    • View reference on publisher's website
    • View reference on PubMed
  6. Chen YY, Connors AF Jr, Garland A (2008) Effect of decisions to withhold life support on prolonged survival. Chest 133:1312–1318
    • View reference on publisher's website
    • View reference on PubMed
  7. Winter B, Cohen S (1999) ABC of intensive care. Withdrawal of treatment. BMJ 319:306–308
    • View reference on publisher's website
    • View reference on PubMed
  8. Luttrell S (1999) Withdrawing or withholding life prolonging treatment. BMJ 318:1709–1710
    • View reference on publisher's website
    • View reference on PubMed
  9. Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, Ledoux D, Lippert A, Maia P, Phelan D, Schobersberger W, Wennberg E, Woodcock T (2003) End-of-life practices in European intensive care units: the Ethicus Study. JAMA 290:790–797
    • View reference on publisher's website
    • View reference on PubMed
  10. Sprung CL, Maia P, Bulow HH, Ricou B, Armaganidis A, Baras M, Wennberg E, Reinhart K, Cohen SL, Fries DR, Nakos G, Thijs LG (2007) The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med 33:1732–1739
  11. Vincent JL (2005) Withdrawing may be preferable to withholding. Crit Care 9:226–229
    • View reference on publisher's website
    • View reference on PubMed
  12. Mark NM, Rayner SG, Lee NJ, Curtis JR (2015) Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med. doi:10.1007/s00134-015-3810-5
  13. Vincent JL (1999) Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med 27:1626–1633
    • View reference on publisher's website
    • View reference on PubMed
  14. The Society of Critical Care Medicine Ethics Committee (1992) Attitudes of critical care medicine professionals concerning forgoing life-sustaining treatments. Crit Care Med 20:320–326
    • View reference on publisher's website
  15. Ferrand E, Robert R, Ingrand P, Lemaire F, French LATAREA Group (2001) Withholding and withdrawal of life support in intensive-care units in France: a prospective survey. Lancet 357:9–14
    • View reference on publisher's website
    • View reference on PubMed
  16. Azoulay E, Metnitz B, Sprung CL, Timsit JF, Lemaire F, Bauer P, Schlemmer B, Moreno R, Metnitz P (2009) End-of-life practices in 282 intensive care units: data from the SAPS 3 database. Intensive Care Med 35:623–630
  17. Meissner A, Genga KR, Studart FS, Settmacher U, Hofmann G, Reinhart K, Sakr Y (2010) Epidemiology of and factors associated with end-of-life decisions in a surgical intensive care unit. Crit Care Med 38:1060–1068
    • View reference on publisher's website
    • View reference on PubMed
  18. Thompson DR (2014) Defining an intermediate step in end-of-life therapy. Crit Care Med 42:465–466
    • View reference on publisher's website
    • View reference on PubMed
  19. Thompson DR (2014) “No escalation of treatment” as a routine strategy for decision-making in the ICU: pro. Intensive Care Med 40:1372–1373
  20. Curtis JR, Rubenfeld GD (2014) “No escalation of treatment” as a routine strategy for decision-making in the ICU: con. Intensive Care Med 40:1374–1376
  21. Azoulay E, Garrouste M, Goldgran-Toledano D, Adrie C, Max A, Vesin A, Francais A, Zahar JR, Cohen Y, Allaouchiche B, Schlemmer B, Timsit JF (2012) Increased nonbeneficial care in patients spending their birthday in the ICU. Intensive Care Med 38:1169–1176
  22. Garrouste-Orgeas M, Ben-Rehouma M, Darmon M, Ruckly S, Clec’h C, Adrie C, Tabah A, Vesin A, Schwebel C, Misset B, Timsit JF (2014) ICU physician-based determinants of life-sustaining therapy during nights and weekends: French multicenter study from the Outcomerea Research Group. Crit Care Med 42:2393–2400
    • View reference on publisher's website
    • View reference on PubMed
  23. (2009) Limitation et Arrêt des Traitements en Réanimation Adulte. Recommandations de la Société de Réanimation de Langue Française. http://www.srlf.org/data/ModuleGestionDeContenu/application/816.pdf
  24. Le Gall JR, Lemeshow S, Saulnier F (1993) A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963
    • View reference on publisher's website
    • View reference on PubMed
  25. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. On behalf of the working group on sepsis-related problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710
  26. Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84
    • View reference on publisher's website
    • View reference on PubMed
  27. Fassier T, Lautrette A, Ciroldi M, Azoulay E (2005) Care at the end of life in critically ill patients: the European perspective. Curr Opin Crit Care 11:616–623
    • View reference on publisher's website
    • View reference on PubMed
  28. Wunsch H, Harrison DA, Harvey S, Rowan K (2005) End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom. Intensive Care Med 31:823–831
  29. Azoulay E, Pochard F, Garrouste-Orgeas M, Moreau D, Montesino L, Adrie C, de Lassence A, Cohen Y, Timsit JF (2003) Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death. Intensive Care Med 29:1895–1901
  30. Pochard F, Azoulay E, Chevret S, Vinsonneau C, Grassin M, Lemaire F, Herve C, Schlemmer B, Zittoun R, Dhainaut JF (2001) French intensivists do not apply American recommendations regarding decisions to forgo life-sustaining therapy. Crit Care Med 29:1887–1892
    • View reference on publisher's website
    • View reference on PubMed
  31. Bertolini G, Boffelli S, Malacarne P, Peta M, Marchesi M, Barbisan C, Tomelleri S, Spada S, Satolli R, Gridelli B, Lizzola I, Mazzon D (2010) End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units. Intensive Care Med 36:1495–1504
  32. Nathens AB, Rivara FP, Wang J, Mackenzie EJ, Jurkovich GJ (2008) Variation in the rates of do not resuscitate orders after major trauma and the impact of intensive care unit environment. J Trauma 64(81–88):88–91 (discussion)
  33. Hall RI, Rocker GM (2000) End-of-life care in the ICU: treatments provided when life support was or was not withdrawn. Chest 118:1424–1430
    • View reference on publisher's website
    • View reference on PubMed
  34. Bulow HH, Sprung CL, Baras M, Carmel S, Svantesson M, Benbenishty J, Maia PA, Beishuizen A, Cohen S, Nalos D (2012) Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The Ethicatt study. Intensive Care Med 38:1126–1133
  35. Morgan CK, Varas GM, Pedroza C, Almoosa KF (2014) Defining the practice of “no escalation of care” in the ICU. Crit Care Med 42:357–361
    • View reference on publisher's website
    • View reference on PubMed
  36. Zahuranec DB, Brown DL, Lisabeth LD, Gonzales NR, Longwell PJ, Smith MA, Garcia NM, Morgenstern LB (2007) Early care limitations independently predict mortality after intracerebral hemorrhage. Neurology 68:1651–1657
    • View reference on publisher's website
    • View reference on PubMed
  37. Bradford MA, Lindenauer PK, Wiener RS, Walkey AJ (2014) Do-not-resuscitate status and observational comparative effectiveness research in patients with septic shock. Crit Care Med 42:2042–2047
    • View reference on publisher's website
    • View reference on PubMed
  38. Long AC, Kross EK, Engelberg RA, Downey L, Nielsen EL, Back AL, Curtis JR (2014) Quality of dying in the ICU: is it worse for patients admitted from the hospital ward compared to those admitted from the emergency department? Intensive Care Med 40:1688–1697

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement