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Dying in the ICU

Changes in end of life decisions from 2011 to 2018 in the ICU of a communal tertiary hospital in Germany

Sterben auf der Intensivstation

Veränderungen bei Entscheidungen am Lebensende von 2011 bis 2018 auf der Intensivstation eines kommunalen Krankenhauses der Maximalversorgung in Deutschland

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Abstract

Background

With modern intensive care medicine, even older patients and those with pre-existing conditions can survive critical illnesses and major operations; however, unreflected application of intensive care treatment might lead to a state called chronic critical illness. Today, withholding treatment and/or treatment withdrawal precede many deaths in the intensice care unit (ICU). We looked at changes in measures at the end of life and withholding or withdrawal of treatment in the ICU of a German tertiary hospital in 2017/2018 compared to 2011/2012.

Methods

In this retrospective explorative study, we analyzed end of life practices in adult patients who died in an intermediate care unit (IMC)/ICU of Klinikum Hanau in 2017/2018. We compared these data with data from the same hospital in 2011/2012

Results

Of the 1246 adult patients who died in Klinikum Hanau in 2017/2018, 433 (35%) died in an ICU or IMC unit. Deceased ICU patients were 74.0 ± 12.5 years and 86.6% were older than 60 years. At least one life-sustaining measure was withheld in 278 (76.2%) and withdrawn in 159 (46.3%) of patients. More than three quarters of patients (n = 276, 75.6%) had a do not resuscitate (DNR) order and in about half of the patients invasive ventilation (n = 175, 49.9%) or renal replacement therapy (n = 191, 52.3%) was limited. In 113 patients (31.0%) catecholamine treatment was withdrawn, in 72 (19.7%) patients invasive ventilation and in 49 (13.4%) patients renal replacement therapy. Compared to 2011/2012, we saw an increase by ~15% (absolute increase) in withholding and withdrawal of treatment and observed an effect of documents like advance directive or healthcare proxy.

Conclusion

In 76.2% of deceased ICU patients withholding treatment and in 43.6% treatment withdrawal preceded death. Compared to 2011/2012 treatment was withheld or withdrawn more often. Compared to 2011/2012, we saw an increase (~15% absolute) in withholding and withdrawal of treatment. After withholding or withdrawal of treatment, most patients died within 3 and 2 days, respectively.

Zusammenfassung

Hintergrund

Mittels moderner intensivmedizinischer Methoden können auch ältere Menschen und Menschen mit erheblichen Vorerkrankungen größere Operationen und kritische Erkrankungen überleben. Die unkritische Anwendung intensivmedizinischer Maßnahmen kann jedoch auch zu einem Zustand führen, der als chronische kritische Erkrankung bezeichnet wird. Da wahrscheinlich vielen Todesfällen auf der Intensivstation Therapiebegrenzungen oder -abbrüche vorangehen, haben wir Akten von Todesfällen der Jahre 2017/2018 angesehen und mit Daten aus den Jahren 2011/2012 verglichen.

Material und Methoden

In dieser retrospektiven explorativen Arbeit haben wir Todesfälle auf den Intensiv‑/Intermediate-Care-Stationen (chirurgisch/interdisziplinär und konservativ) des Klinikum Hanau in den Jahren 2017/2018 bzgl. Therapiebegrenzungen und Therapieabbrüchen untersucht und diese den Daten aus 2011/2012 gegenübergestellt.

Ergebnisse

In den Jahren 2017/2018 sind 1246 Patienten im Klinikum Hanau verstorben. Davon starben 433 (35 %) auf einer Intensiv‑/Intermediate-Care-Station. Die verstorbenen Intensivpatienten waren im Mittel 74,0 ± 12,5 Jahre alt und 86,6 % waren älter als 60 Jahre. Bei 278 Patienten (76,2 %) wurde mindestens eine Maßnahme begrenzt, bei 159 (46,3 %) mindestens eine Maßnahme abgebrochen. Mehr als drei Viertel aller Patienten (276, 75,6 %) hatte eine „Do-not-resuscitate“(DNR)-Anordnung, und bei über der Hälfte der Verstorbenen wurde die invasive Beatmung (n = 175, 49,9 %) oder eine Nierenersatztherapie (n = 191, 52,3 %) begrenzt. Bei 113 Patienten (31,0 %) wurde die Katecholamintherapie, bei 72 (19,7 %) Patienten die invasive Beatmung und bei 49 (13,4 %) Patienten eine Nierenersatztherapie abgebrochen. Sowohl bei den Therapiebegrenzungen wie auch den -abbrüchen sind die Zahlen im Vergleich zu 2011/2012 um ca. absolute 15 % (absolute Zunahme) gestiegen wobei ein Effekt von Vorsorgedokumenten zu erkennen war.

Diskussion

Bei 76,2 % der verstorbenen Intensivpatienten wurde eine Therapie begrenzt und bei 43,6 % abgebrochen. Im Vergleich zu 2011/2012 sind mehr Therapien begrenzt und abgebrochen worden. Nach Begrenzung oder Abbruch einer Therapie sind die meisten Patienten innerhalb von 3 bzw. 2 Tagen verstorben.

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Abbreviations

BPM:

Blood pressure measurement

CPR:

Cardiopulmonary resuscitation

CVL:

Central venous line

DNR:

Do not resuscitate

DRG:

German diagnosis-related group

ICU:

Intensive care unit

IMC:

Intermediate care unit

IV:

Invasive ventilation

NGT:

Nasogastral tube

NIV:

Noninvasive ventilation

RRT:

Renal replacement therapy

PRG/PEJ:

Percutaneous endoscopic gastrostomy/jejunostomy

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Acknowledgements

We thank Mrs. Esma Ay for introducing IS in analysis of patients’ charts and many helpful discussions about end-of-life decisions.

Funding

None; this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Department of Neurology, Klinikum Hanau GmbH, Leimenstr. 20, 63450, Hanau, Germany

    Isabel Schulmeyer

  2. Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany

    Markus A. Weigand MD

  3. MH-Statistical Consulting, Bienenweg 8, 35041, Marburg, Germany

    Monika Heinzel-Gutenbrunner PhD

  4. Department of Anaesthesiolology, Intensive Care Medicine and Pain Therapy, Klinikum Hanau GmbH, Leimenstr. 20, 63450, Hanau, Germany

    Marco Gruss MD

Authors
  1. Isabel Schulmeyer
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Contributions

IS analyzed the patients’ charts, made the figure and tables. MAW had the idea for the study and made substantial reviews. MHG supported the study design and calculated the statistical analysis. MG had the idea for the study, planned it, carried it out and wrote the manuscript.

Corresponding author

Correspondence to Marco Gruss MD.

Ethics declarations

Conflict of interest

I. Schulmeyer, M.A. Weigand, M. Heinzel-Gutenbrunner and M. Gruss declare that they have no competing interests.

Ethical approval was given before analyzing data by the Medical Council (Landesärztekammer) Hesse (AZ 2019-1244-evBO, 28.11.2019, second period and FF 131/2013, 23.01.2014, first period).

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Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request

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Schulmeyer, I., Weigand, M.A., Heinzel-Gutenbrunner, M. et al. Dying in the ICU. Anaesthesiologie 71, 930–940 (2022). https://doi.org/10.1007/s00101-022-01127-6

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