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
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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.
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.
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).
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.
KeywordsCritical care Decision-making Prognosis End-of-life Do-not-resuscitate
We are indebted to Mr. Jeffrey Watts and Prof. Elie Azoulay for assistance in the preparation of the manuscript.
Conflicts of interest
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflict of Interest. Dr. Darmon served as lecturer for Bristol-Myers Squibb and Astellas. His institution received grant support from MSD and Astute. Dr. Timsit served as a board member for Brahms, Pfizer, Merck, Gilead, and Astellas (participation to symposiums as speaker); consulted for Merck and Astellas (board of epidemiological studies); and received support for development of educational presentations (Gilead educational pack of slides about candidal infections). His institution received grant support from Astellas (research grants), 3M (research grants), Merck (research grants), Pfizer (research grants), and Gilead (research and educational grants). The remaining authors declare no potential conflict of interest.
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