End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
To appraise the end-of-life decision-making in several intensive care units (ICUs) and to evaluate the association between the average inclination to limit treatment and overall survival at ICU level.
Prospective, multicenter, observational study, lasting 12 months.
Eighty-four Italian, adult ICUs.
Consecutive patients (3,793) who died in ICU or were discharged in terminal condition, in 2005.
Data collection included patient description, treatment limitation and decision-makers, involvement of patients and relatives in the decision, and organ donation. A logistic regression model was used to identify predictors of treatment limitation and develop a measure of the inclination to limit treatment for each ICU. This was compared with the standardized mortality ratio, an index of the overall performance of the unit.
Treatment limitation preceded 62% of deaths. In 25% of cases, nurses were involved in the decision. Half the limitations were do-not-resuscitate orders, with the remaining half almost equally split between withholding and withdrawing treatment. Units less inclined to limit treatments (odds ratio <0.77) showed higher overall standardized mortality ratio (1.08; 95% confidence interval: 1.04–1.12).
The voluntary nature of participation, with self-selected ICUs from a self-selected independent network.
Treatment limitation is common in ICU and still principally a physician’s responsibility. Units with below-average inclination to limit treatments have worse performance in terms of overall mortality, showing that limitation is not against the patient’s interests. On the contrary, the inclination to limit treatments at the end of life can be taken as an indication of quality in the unit.
- Anonymous (2001) Medical treatment at the end of life. A position statement. Clin Med 1:115–117
- SIAARTI (2006) End-of-life care and the intensivist: SIAARTI recommendations on the management of the dying patient. Minerva Anestesiol 72:927–963
- Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, Hinds C, Pimentel JM, Reinhart K, Thompson BT (2004) Challenges in end-of-life care in the ICU. Statement of the fifth international consensus conference in critical care: Brussels, Belgium, April 2003. Intensive Care Med 30:770–784
- Patrick DL, Curtis JR, Engelberg RA, Nielsen E, McCown E (2003) Measuring and improving the quality of dying and death. Ann Intern Med 139:410–415
- Selecky PA, Eliasson CA, Hall RI, Schneider RF, Varkey B, McCaffree DR (2005) Palliative and end-of-life care for patients with cardiopulmonary diseases: American college of chest physicians position statement. Chest 128:3599–3610 CrossRef
- Truog RD, Cist AF, Brackett SE, Burns JP, Curley MA, Danis M, DeVita MA, Rosenbaum SH, Rothenberg DM, Sprung CL, Webb SA, Wlody GS, Hurford WE (2001) Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the society of critical care medicine. Crit Care Med 29:2332–2348 CrossRef
- Boffelli S, Rossi C, Anghileri A, Giardino M, Carnevale L, Messina M, Neri M, Langer M, Bertolini G (2006) Continuous quality improvement in intensive care medicine. The GiViTI Margherita project—Report 2005. Minerva Anestesiol 72:419–432
- Boffelli S, Rossi C, Bertolini G (2006) Progetto Margherita, Promuovere la ricerca e la valutazione in Terapia Intensiva. Rapporto 2005. (English version available at: http://www.giviti.marionegri.it/MargheritaDue.asp). Ed. Sestante, Bergamo
- Teres D (2004) The value and limits of severity adjusted mortality for ICU patients. J Crit Care 19:257–263 CrossRef
- Hosmer DW, Lemeshow S (1995) Confidence interval estimates of an index of quality performance based on logistic regression models. Stat Med 14:2161–2172 CrossRef
- 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 CrossRef
- 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
- Ferrand E, Robert R, Ingrand P, Lemaire F (2001) Withholding and withdrawal of life support in intensive-care units in France: a prospective survey. French LATAREA Group. Lancet 357:9–14 CrossRef
- 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 CrossRef
- 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 CrossRef
- White DB, Curtis JR, Wolf LE, Prendergast TJ, Taichman DB, Kuniyoshi G, Acerra F, Lo B, Luce JM (2007) Life support for patients without a surrogate decision maker: who decides? Ann Intern Med 147:34–40
- 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 CrossRef
- 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 CrossRef
- Cook D, Rocker G, Marshall J, Sjokvist P, Dodek P, Griffith L, Freitag A, Varon J, Bradley C, Levy M, Finfer S, Hamielec C, McMullin J, Weaver B, Walter S, Guyatt G (2003) Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 349:1123–1132 CrossRef
- Luce JM (1997) Withholding and withdrawal of life support: ethical, legal, and clinical aspects. New Horiz 5:30–37
- Anonymous (1991) Withholding and withdrawing life-sustaining therapy. This official statement of the American thoracic society was adopted by the ATS Board of Directors, March 1991. Am Rev Respir Dis 144:726–731
- Miller PA, Forbes S, Boyle DK (2001) End-of-life care in the intensive care unit: a challenge for nurses. Am J Crit Care 10:230–237
- End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units
Intensive Care Medicine
Volume 36, Issue 9 , pp 1495-1504
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- Intensive care units
- Critically ill
- Industry Sectors
- Author Affiliations
- 1. Laboratorio di Epidemiologia Clinica, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò, Istituto di Ricerche Farmacologiche Mario Negri, 24020, Ranica, BG, Italy
- 2. Servizio di Anestesia, Rianimazione e Pronto Soccorso, Ospedale di S. Chiara, Pisa, Italy
- 3. I Servizio Anestesia e Rianimazione, Ospedale Regionale Ca’ Foncello, Treviso, Italy
- 4. I Servizio Anestesia e Rianimazione, Ospedali Riuniti, Bergamo, Italy
- 5. Comitato Etico, Ospedale Regionale Ca’ Foncello, Treviso, Italy
- 6. Centro di Ricerca Interdisciplinare Scienze Umane, Salute e Malattia, Università degli Studi, Bergamo, Italy
- 7. Servizio di Psicologia Clinica, Ospedali Riuniti, Bergamo, Italy
- 8. Agenzia Zadig, Milan, Italy
- 10. University of Pittsburgh Medical Center (UPMC), Pittsburgh, USA
- 9. Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IsMeTT), Palermo, Italy
- 11. Servizio Anestesia e Rianimazione, Ospedale Civile San Martino, Belluno, Italy