Intensive Care Medicine

, Volume 41, Issue 10, pp 1763–1772 | Cite as

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

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



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.


Critical 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.


No grant.

Supplementary material

134_2015_3944_MOESM1_ESM.doc (184 kb)
Supplementary material 1 (DOC 184 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2015

Authors and Affiliations

  • Alexandre Lautrette
    • 1
    • 2
  • Maïté Garrouste-Orgeas
    • 3
  • Pierre-Marie Bertrand
    • 1
  • Dany Goldgran-Toledano
    • 4
  • Samir Jamali
    • 5
  • Virginie Laurent
    • 6
  • Laurent Argaud
    • 7
  • Carole Schwebel
    • 8
  • Bruno Mourvillier
    • 9
  • Michaël Darmon
    • 10
  • Stéphane Ruckly
    • 11
  • Anne-Sylvie Dumenil
    • 12
  • Virginie Lemiale
    • 13
  • Bertrand Souweine
    • 1
    • 2
  • Jean-François Timsit
    • 9
    • 11
  • Outcomerea Study Group
  1. 1.Medical Intensive Care Unit, Gabriel Montpied Teaching HospitalUniversity Hospital of Clermont-FerrandClermont-Ferrand Cedex 1France
  2. 2.LMGE (Laboratoire Micro-organismes: Génome et Environnement), UMR CNRS 6023Clermont-UniversityClermont-FerrandFrance
  3. 3.Critical Care Medicine UnitSaint-Joseph HospitalParisFrance
  4. 4.Critical Care Medicine UnitGonesse HospitalGonesseFrance
  5. 5.Critical Care Medicine UnitDourdan HospitalDourdanFrance
  6. 6.Critical Care Medicine UnitVersailles HospitalLe ChesnayFrance
  7. 7.Medical Intensive Care Unit, Edouard Herriot Teaching HospitalUniversity of LyonLyonFrance
  8. 8.Medical Intensive Care Unit, Albert Michallon Teaching HospitalUniversity Hospital of GrenobleGrenobleFrance
  9. 9.Medical Intensive Care UnitBichat-Claude Bernard Teaching Hospital, AP-HPParisFrance
  10. 10.Medical Intensive Care Unit, Nord Teaching HospitalUniversity of Saint EtienneSaint EtienneFrance
  11. 11.U823 “Outcome of cancers and critical illness”Albert Bonniot InstituteLa TroncheFrance
  12. 12.Surgical Intensive Care UnitAntoine Beclere University HospitalClamartFrance
  13. 13.Medical Intensive Care UnitSaint Louis Teaching Hospital, AP-HPParisFrance

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