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Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death

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Abstract

Objective

More than one-half the deaths of patients admitted to intensive care units (ICUs) occur after a decision to forgo life-sustaining therapy (DFLST). Although DFLSTs typically occur in patients with severe comorbidities and intractable acute medical disorders, other factors may influence the likelihood of DFLSTs. The objectives of this study were to describe the factors and mortality associated with DFLSTs and to evaluate the potential independent impact of DFLSTs on hospital mortality.

Design and setting

Prospective multicenter 2-year study in six ICUs in France.

Patients

The 1,698 patients admitted to the participating ICUs during the study period, including 295 (17.4%) with DFLSTs.

Measurements and results

The impact of DFLSTs on hospital mortality was evaluated using a model that incorporates changes in daily logistic organ dysfunction scores during the first ICU week. Univariate predictors of death included demographic factors (age, gender), comorbidities, reasons for ICU admission, severity scores at ICU admission, and DFLSTs. In a stepwise Cox model five variables independently predicted mortality: good chronic health status (hazard ratio, 0.479), SAPS II score higher than 39 (2.05), chronic liver disease (1.463), daily logistic organ dysfunction score (1.357 per point), and DFLSTs (1.887).

Conclusions

DFLSTs remain independently associated with death after adjusting on comorbidities and severity at ICU admission and within the first ICU week. This highlights the need for further clarifying the many determinants of DFLSTs and for routinely collecting DFLSTs in studies with survival as the outcome variable of interest.

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Acknowledgements

The authors are indebted to A. Wolfe, MD, for her help in preparing this manuscript and to S. Chevret, MD, PhD, for her critical reading of the manuscript and help in selecting the statistical models. The Outcomerea Study Group includes: Saint-Louis Teaching Hospital (Medical ICU Department and Biostatistics department), Cochin Teaching Hospital (Psychiatry Department), Saint-Joseph Teaching Hospital (Medical-Surgical ICU), Bichat Teaching Hospital (Medical-Surgical ICU), Saint-Denis Teaching Hospital (Medical-Surgical ICU), Louis Mourier Teaching Hospital (Medical ICU), and Avicenne Teaching Hospital (Medical-Surgical ICU).

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Authors and Affiliations

  1. Saint-Louis Teaching Hospital, Medical ICU Department, 1 Avenue Claude Vellefaux, 75010, Paris, France

    Élie Azoulay & Delphine Moreau

  2. Cochin Teaching Hospital, Psychiatry Department, 27 rue du faubourg St Jacques, 75014, Paris, France

    Frédéric Pochard

  3. Saint-Joseph Teaching Hospital, Medical-Surgical ICU, 185 rue Raymond Losserand, 75014, Paris, France

    Maité Garrouste-Orgeas

  4. Bichat Teaching Hospital, Medical-Surgical ICU, 46 rue Henri Huchard, 75018, Paris, France

    Laurent Montesino & Jean-François Timsit

  5. Saint-Denis Teaching Hospital, Medical-Surgical ICU, 2 rue du Docteur Delafontaine, 93200, Saint Denis, France

    Christophe Adrie

  6. Louis Mourier Teaching Hospital, Medical ICU, 178 rue des Renouillers, 92700, Colombes, France

    Arnaud de Lassence

  7. Avicenne Teaching Hospital, Medical-Surgical ICU, 125 rue de Stalingrad, 93000, Bobigny, France

    Yves Cohen

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  1. Élie Azoulay
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  2. Frédéric Pochard
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  9. Jean-François Timsit
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on the behalf of the Outcomerea Study Group

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Correspondence to Élie Azoulay.

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Outcomerea receives an unrestricted grant from the Centre National pour la Recherche Scientifique.

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Azoulay, É., Pochard, F., Garrouste-Orgeas, M. et al. Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death. Intensive Care Med 29, 1895–1901 (2003). https://doi.org/10.1007/s00134-003-1989-3

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  • DOI: https://doi.org/10.1007/s00134-003-1989-3

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