Journal Article

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

Lautrette, Alexandre, Jamali, Samir, Bertrand, Pierre-Marie, Goldgran-Toledano, Dany, Darmon, Michaël, Ruckly, Stéphane, Souweine, Bertrand, Argaud, Laurent, Dumenil, Anne-Sylvie, Timsit, Jean-François, Garrouste-Orgeas, Maïté, Lemiale, Virginie, Schwebel, Carole, Mourvillier, Bruno, Laurent, Virginie

2015

Overview

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.

• Publisher: Springer Berlin Heidelberg,Springer,Springer Nature B.V,Springer Verlag
• Subject: Adult / Aged / Analysis / Anesthesiology / Chronic diseases / Critical care / Critical Care Medicine / Decision Making / Emergency Medicine / Female / France / Health aspects / Hospital patients / Human health and pathology / Humans / Illnesses / Infectious diseases / Intensive / Intensive care / Intensive Care Units - statistics & numerical data / Life Sciences / Life Support Care - statistics & numerical data / Male / Medical research / Medicine / Medicine & Public Health / Medicine, Experimental / Middle Aged / Mortality / Observational studies / Observational Studies as Topic / Original / Pain Medicine / Pediatrics / Physicians / Pneumology/Respiratory System / Prognosis / Prospective Studies / Resuscitation Orders / Teaching hospitals / Withholding Treatment - statistics & numerical data