Intensive Care Medicine

, Volume 36, Issue 9, pp 1495–1504 | Cite as

End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units

  • Guido Bertolini
  • Simona Boffelli
  • Paolo Malacarne
  • Mario Peta
  • Mariano Marchesi
  • Camillo Barbisan
  • Stefano Tomelleri
  • Simonetta Spada
  • Roberto Satolli
  • Bruno Gridelli
  • Ivo Lizzola
  • Davide Mazzon



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.


Intensive care units Critically ill End-of-life Decision-making Ethics 



Guido Bertolini had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The study was wholly funded by GiViTI-Istituto di Ricerche Farmacologiche Mario Negri, Bergamo (Italy), Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IsMeTT), Palermo (Italy), and Centro di Ricerca Interdisciplinare Scienze Umane, Salute e Malattia, Università degli Studi, Bergamo (Italy). GiViTI is the recipient of unconditioned grants from AstraZeneca Italy and Draeger Italia, which did not, however, have any role in this study. The authors would like to thank Abramo Anghileri and Michele Giardino (Istituto di Ricerche Farmacologiche Mario Negri) for having developed the data collection software, and Warren Blumberg for his help in editing this paper.

Conflict of interest statement


Supplementary material

134_2010_1910_MOESM1_ESM.doc (266 kb)
Supplementary material 1 (DOC 265 kb)


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Copyright information

© Copyright jointly held by Springer and ESICM 2010

Authors and Affiliations

  • Guido Bertolini
    • 1
  • Simona Boffelli
    • 1
  • Paolo Malacarne
    • 2
  • Mario Peta
    • 3
  • Mariano Marchesi
    • 4
  • Camillo Barbisan
    • 5
  • Stefano Tomelleri
    • 6
  • Simonetta Spada
    • 7
  • Roberto Satolli
    • 8
  • Bruno Gridelli
    • 9
    • 10
  • Ivo Lizzola
    • 6
  • Davide Mazzon
    • 11
  1. 1.Laboratorio di Epidemiologia Clinica, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele DaccòIstituto di Ricerche Farmacologiche Mario NegriRanicaItaly
  2. 2.Servizio di Anestesia, Rianimazione e Pronto SoccorsoOspedale di S. ChiaraPisaItaly
  3. 3.I Servizio Anestesia e RianimazioneOspedale Regionale Ca’ FoncelloTrevisoItaly
  4. 4.I Servizio Anestesia e RianimazioneOspedali RiunitiBergamoItaly
  5. 5.Comitato EticoOspedale Regionale Ca’ FoncelloTrevisoItaly
  6. 6.Centro di Ricerca Interdisciplinare Scienze UmaneSalute e Malattia, Università degli StudiBergamoItaly
  7. 7.Servizio di Psicologia ClinicaOspedali RiunitiBergamoItaly
  8. 8.Agenzia ZadigMilanItaly
  9. 9.Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IsMeTT)PalermoItaly
  10. 10.University of Pittsburgh Medical Center (UPMC)PittsburghUSA
  11. 11.Servizio Anestesia e RianimazioneOspedale Civile San MartinoBellunoItaly

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