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Withholding or withdrawing of life-sustaining therapy in older adults (≥ 80 years) admitted to the intensive care unit

Bertrand Guidet| Hans Flaatten| Ariane Boumendil| Alessandro Morandi| Finn H. Andersen| Antonio Artigas| Guido Bertolini| Maurizio Cecconi| Steffen Christensen| Loredana Faraldi| Jesper Fjølner| Christian Jung| Brian Marsh| Rui Moreno| Sandra Oeyen| Christina Agwald Öhman| Bernardo Bollen Pinto| Ivo W. Soliman| Wojciech Szczeklik| Andreas Valentin| Ximena Watson| Tilemachos Zafeiridis| Dylan W. De
Original
Volume 44, Issue 7 / July , 2018

Pages 1027 - 1038

Abstract

Purpose

To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU.

Methods

This prospective study included intensive care patients aged ≥ 80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up.

Results

LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32–7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78–2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12–1.34) and SOFA score [OR of 1.07 (95% CI 1.05–1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries.

Conclusions

The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country.

Trial registration

ClinicalTrials.gov (ID: NTC03134807).

Keywords

References

  1. Flaatten H, Artigas A, de Lange DW, Bin D, Moreno R, Christensen S, Joynt GM, Bagshaw SM, Sprung CL, Benoit D, Soares M, Guidet B (2017) The status of ICM research and a future agenda for very elderly patients in the ICU. Intensive Care Med 43:1319–1328
  2. Angus D (2017) Admitting elderly patients to the intensive care unit—is it the right decision? JAMA 318:1443–1444
    • View reference on publisher's website
    • View reference on PubMed
  3. Laake JH, Dybwik K, Flaatten HK, Fonneland I-L, Kvåle R, Strand K (2010) Impact of the post-World War II generation on intensive care needs in Norway. Acta Anaesthesiol Scand 54:479–484
    • View reference on publisher's website
    • View reference on PubMed
  4. Flaatten H, De Lange D, Morandi A et al (2017) The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (≥ 80 years). Intensive Care Med 43:4940–4948
  5. Sprung CL, Danis M, Iapichino G, Artigas A, Kesecioglu J, Moreno R, Lippert A, Curtis JR, Meale P, Cohen SL, Levy MM, Truog RD (2013) Triage of intensive care patients: identifying agreement and controversy. Intensive Care Med 39:1916–1924
  6. Boumendil A, Angus DC, Guitonneau AL, Menn AM, Ginsburg C, Takun K, Davido A, Masmoudi R, Doumenc B, Pateron D, Garrouste-Orgeas M, Somme D, Simon T, Aegerter Ph, Guidet B (2012) Variability of intensive care admission decisions for the very elderly. Plos One 7(1–11):e34387
    • View reference on publisher's website
    • View reference on PubMed
  7. Sprung CL, Woodcock T, Sjokvist P, Ricou B, Bulow HH, Lippert A, Maia P, Cohen S, Baras M, Hovilehto S, Ledoux D, Phelan D, Wennberg E, Schobersberger W (2008) Reasons, considerations, difficulties and documentation of end-of-life decisions in European intensive care units: the ETHICUS Study. Intensive Care Med 34:271–277
  8. Guidet B, de Lange D, Flaatten H (2018) Should this elderly patient be admitted to the ICU. Intensive Care Medicine. https://doi.org/10.1007/s00134-018-5054-7(Epub ahead of print)
  9. Guidet B, De Lange DW, Christensen S, Moreno R, Fjølner J, Dumas G, Flaatten H (2018) Attitudes of physicians towards the care of critically ill elderly patients—a European survey. Acta Anaesthesiol Scand 62:207–219
    • View reference on publisher's website
    • View reference on PubMed
  10. Le Guen J, Boumendil A, Guidet B, Corvol A, Saint-Jean O, Somme D (2016) Are elderly patients’ opinions sought before admission to an intensive care unit? Results of the ICE-CUB study. Age Ageing 45:303–309
    • View reference on publisher's website
    • View reference on PubMed
  11. Lecuyer L, Chevret S, Thiery G, Darmon M, Schlemmer B, Azoulay E (2007) The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med 35:808–814
    • 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 41:1572–1585
  13. Quill CM, Ratcliffe SJ, Harhay MO, Halpern SD (2014) Variation in decisions to forgo life-sustaining therapies in US ICUs. Chest 146(573–582):5
  14. Hart JL, Harhay MO, Gabler NB, Ratcliffe SJ, Quill CM, Halpern SD (2015) Variability among US intensive care units in managing the care of patients admitted with preexisting limits on life-sustaining therapies. JAMA Intern Med 175:1019–1026
    • View reference on publisher's website
    • View reference on PubMed
  15. Barnato AE, Herndon MB, Anthony DL, Gallagher PM, Skinner JS, Bynum JP, Fisher ES (2007) Are regional variations in end-of-life care intensity explained by patient preferences?: a study of the US Medicare population. Med Care 45:386–393
    • View reference on publisher's website
    • View reference on PubMed
  16. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I et al (2005) A global clinical measure of fitness and frailty in elderly people. CMAJ 173:489–495
    • View reference on publisher's website
    • View reference on PubMed
  17. Vincent JL, Moreno R, Takala J, Willatts S, de Mendonça A, Bruining H et al (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
  18. Guidet B, Hodgson E, Feldman C, Paruk F, Lipman J, Koh Y, Vincent JL, Azoulay E, Sprung C (2014) The Durban World Congress Ethics Round Table conference report: II. Withholding or withdrawing of treatment in elderly patients admitted to the Intensive Care Unit. J Crit Care 29:896–901
    • View reference on publisher's website
    • View reference on PubMed
  19. 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; Ethicus Study Group (2003) End-of-life practices in European intensive care units: the Ethicus Study. JAMA 290:790–797
    • View reference on publisher's website
  20. 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(6):823–831
  21. Curtis JR, Engelberg RA, Teno JM (2017) Understanding variability of end-of-life care in the ICU for the elderly. Intensive Care Med 43:194–196
  22. Sprung CL, Maia P, Bulow HH, Ricou B, Armaganidis A, Baras M, Wennberg E, Reinhart K, Cohen SL, Fries DR, Nakos G, Thijs LG; Ethicus Study Group (2007) The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med 33:1732–1739
  23. 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. French LATAREA Group. Lancet 357(9249):9–14
    • View reference on publisher's website
  24. Hamel MB, Davis RB, Teno JM et al (1999) Older age, aggressiveness of care, and survival for seriously ill, hospitalized adults. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. Ann Intern Med 131:721–728
    • View reference on publisher's website
    • View reference on PubMed
  25. Hamel MB, Teno JM, Goldman L et al (1999) Patient age and decisions to withhold life-sustaining treatments from seriously ill, hospitalized adults. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatment. Ann Intern Med 130:116–125
    • View reference on publisher's website
    • View reference on PubMed
  26. Hakim RB, Teno JM, Harrell FE Jr et al (1996) Factors associated with do-not-resuscitate orders: patients’ preferences, prognoses, and physicians’ judgments. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatment. Ann Intern Med 125:284–293
    • View reference on publisher's website
    • View reference on PubMed
  27. 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
  28. Orban JC, Walrave Y, Mongardon N, Allaouchiche B, Argaud L, Aubrun F, Barjon G, Constantin JM, Dhonneur G, Durand-Gasselin J, Dupont H, Genestal M, Goguey C, Goutorbe P, Guidet B, Hyvernat H, Jaber S, Lefrant JY, Mallédant Y, Morel J, Ouattara A, Pichon N, Guérin Robardey AM, Sirodot M, Theissen A, Wiramus S, Zieleskiewicz L, Leone M, Ichai C, Network AzuRéa (2017) Causes and characteristics of death in intensive care units: a prospective multicenter study. Anesthesiology 126:882–889
    • View reference on publisher's website
    • View reference on PubMed
  29. 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
  30. Weimer JM, Nowacki AS, Frontera JA (2016) Withdrawal of life-sustaining therapy in patients with intracranial hemorrhage: self-fulfilling prophecy or accurate prediction of outcome? Crit Care Med 44:1161–1172
    • View reference on publisher's website
    • View reference on PubMed
  31. Lautrette A, Garrouste-Orgeas M, Bertrand PM, Goldgran-Toledano D, Jamali S, Laurent V, Argaud L, Schwebel C, Mourvillier B, Darmon M, Ruckly S, Dumenil AS, Lemiale V, Souweine B, Timsit JF; Outcomerea Study Group (2015) 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. Intensive Care Med 41:1763–1772
  32. Cooke CR, Hotchkin DL, Engelberg RA, Rubinson L, Curtis JR (2010) Predictors of time to death after terminal withdrawal of mechanical ventilation in the ICU. Chest 138(2):289–297
    • View reference on publisher's website
    • View reference on PubMed
  33. Bagshaw SM, Webb SA, Delaney A, George C, Pilcher D, Hart GK, Bellomo R (2009) Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis. Crit Care 13:R45
    • View reference on publisher's website
    • View reference on PubMed
  34. Strand K, Walther SM, Reinikainen M, Ala-Kokko TI, Nolin T, Martner J et al (2010) Variations in the length of stay of intensive care unit nonsurvivors in three Scandinavian countries. Crit Care 14:R175
    • View reference on publisher's website
    • View reference on PubMed
  35. Guidet B, Leblanc G, Simon T, Woimant M, Quenot JP, Ganansia O, Maignan M, Yordanov Y, Delerme S, Doumenc B, Fartoukh M, Charestan P, Trognon P, Galichon B, Javaud N, Patzak A, Garrouste-Orgeas M, Thomas C, Azerad S, Pateron D, Boumendil A; ICE-CUB 2 Study Network (2017) Effect of systematic intensive care unit triage on long-term mortality among critically ill elderly patients in france: a randomized clinical trial. JAMA 318:1450–1459
    • View reference on publisher's website
  36. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC (2008) Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med 36:953–963
    • View reference on publisher's website
    • View reference on PubMed
  37. Rhodes A, Ferdinande P, Flaatten H, Guidet B, Metnitz PG, Moreno RP (2012) The variability of critical care beds numbers in Europe. Intensive Care Med 38:1647–1653. https://doi.org/10.1007/s00134-018-5196-7

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