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

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Abstract

Purpose

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.

Design

Prospective, multicenter, observational study, lasting 12 months.

Setting

Eighty-four Italian, adult ICUs.

Patients

Consecutive patients (3,793) who died in ICU or were discharged in terminal condition, in 2005.

Measurements

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.

Results

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).

Limitations

The voluntary nature of participation, with self-selected ICUs from a self-selected independent network.

Conclusions

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.

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Acknowledgments

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

None.

Author information

Authors and Affiliations

  1. Laboratorio di Epidemiologia Clinica, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò, Istituto di Ricerche Farmacologiche Mario Negri, 24020, Ranica, BG, Italy

    Guido Bertolini & Simona Boffelli

  2. Servizio di Anestesia, Rianimazione e Pronto Soccorso, Ospedale di S. Chiara, Pisa, Italy

    Paolo Malacarne

  3. I Servizio Anestesia e Rianimazione, Ospedale Regionale Ca’ Foncello, Treviso, Italy

    Mario Peta

  4. I Servizio Anestesia e Rianimazione, Ospedali Riuniti, Bergamo, Italy

    Mariano Marchesi

  5. Comitato Etico, Ospedale Regionale Ca’ Foncello, Treviso, Italy

    Camillo Barbisan

  6. Centro di Ricerca Interdisciplinare Scienze Umane, Salute e Malattia, Università degli Studi, Bergamo, Italy

    Stefano Tomelleri & Ivo Lizzola

  7. Servizio di Psicologia Clinica, Ospedali Riuniti, Bergamo, Italy

    Simonetta Spada

  8. Agenzia Zadig, Milan, Italy

    Roberto Satolli

  9. Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IsMeTT), Palermo, Italy

    Bruno Gridelli

  10. University of Pittsburgh Medical Center (UPMC), Pittsburgh, USA

    Bruno Gridelli

  11. Servizio Anestesia e Rianimazione, Ospedale Civile San Martino, Belluno, Italy

    Davide Mazzon

Authors
  1. Guido Bertolini
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  2. Simona Boffelli
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  3. Paolo Malacarne
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  4. Mario Peta
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  5. Mariano Marchesi
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  6. Camillo Barbisan
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  7. Stefano Tomelleri
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  8. Simonetta Spada
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  9. Roberto Satolli
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  10. Bruno Gridelli
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  11. Ivo Lizzola
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  12. Davide Mazzon
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Corresponding author

Correspondence to Guido Bertolini.

Additional information

For the GiViTI group Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva (Italian Group for the Evaluation of Interventions in Intensive Care Medicine). A complete list of study participants appears in the Appendix.

Electronic supplementary material

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Supplementary material 1 (DOC 265 kb)

Appendices

Appendix: List of participating clinicians

Massimo Gianni, Regionale della Valle d’Aosta, Aosta; Armando Nasso, Madonna del Soccorso, A.S.U.R. Zona N. 12, San Benedetto del Tronto (AP); Silvia Perno, Civile, ASL 19, Asti; Livio Cocco, di Ariano Irpino, Ariano Irpino (AV); Adalgisa Caracciolo, Generale Regionale Miulli, Acquaviva delle Fonti (BA); Pierfrancesco Di Masi, IRCCS De Bellis, Castellana Grotte (BA); Manuel Moretti, Riuniti, Bergamo; Davide Mazzon, Civile San Martino di Belluno, Belluno (BL); Cristina Luise, S. Maria del Prato, Feltre (BL); Cinzia Abate, Sacro Cuore di Gesù Fatebenefratelli, Benevento (BN); Aristide Morigi, Ortopedico Rizzoli, Bologna; Maria Cristina Zotti, Spedali Civili, Brescia; Giuseppe Natalini, Poliambulanza, Brescia; Benvenuto Antonini, Spedali Civili, Brescia; Anna Pedemonte, Marino, ASL 8, Cagliari; Elisabetta Brizio, SS. Annunziata, Savigliano (CN); Maurizio Rossi, Sant’Anna di Como, Presidio Ospedaliero di Menaggio, Menaggio (CO); Patrizia Ruggeri, Ospitaliero, Cremona; Maria Rosaria Vitale, Giannattasio, Rossano (CS); Giuseppe Garofalo, P.O. San Bambino, A.O. Universitaria Vittorio Emanuele, Catania; Vincenzo Bonaccorso, Vittorio Emanuele, Catania; Francesco Cocciolo, Bufalini, Cesena; Emiliano Gamberini, Maurizio Bufalini, Cesena; Armando Pedullà, S. Maria Annunziata, ASL 10/H, Antella (FI); Remo Barbagli, CTO Policlinico Careggi, Firenze; Cecilia Pelagatti, Policlinico Careggi, Firenze; Roberto Oggioni, S. Giovanni di Dio, ASL 10, Firenze; Massimo Barattini, Santa Maria Nuova, ASL 10, Firenze; Romano Giuntini, ASL 11, Fucecchio (FI); Michele Isetta, Azienda Ospedaliera Villa Scassi, Genova; Enrico Cinque, Chiavarese, Polo Ospedaliero Lavagna, ASL 4, Lavagna (GE); Mario Tavola, A. Manzoni, Lecco; Giancarlo Negro, Francesco Ferrari, Casarano (LE); Marco Chiarello, ASL 10, Camerino (MC); Antonio David, Universitaria Policlinico G. Martino, Messina; Maurizio Solca, Uboldo, Cernusco sul Naviglio (MI); Ambrogina Cattaneo, E. Bassini, Cinisello Balsamo (MI); Donatella Pinciroli, Civile, Legnano (MI); Giovanni Negri, G. Fornaroli, Magenta (MI); Ludovica Ughi, Fondazione Ospedale Maggiore Policlinico Mangiagalli Regina Elena, Milano; Alberto Sicignano, IRCCS Policlinico Maggiore, Milano; Stefano Rotelli, IRCCS Policlinico Maggiore, Milano; Raffaella Reineke, San Raffaele IRCCS, Milano; Simona Rossi, Civile G. Salvini, Rho (MI); Stefano Clementi, Città di Sesto San Giovanni, Sesto San Giovanni (MI); Elisa Bellocchio, A.O. Carlo Poma Mantova, P.O. Destra Secchia, Pieve di Coriano (MN); Stefano Antonelli, di Carrara, Carrara; Pierantonio Furfori, G. Pasquinucci, Massa; Alberto Guadagnucci, SS. Giacomo e Cristoforo, Massa; Maurizio Postiglione, Santa Maria di Loreto, Napoli; Pasquale Catanzaro, ARNAS Civico e Benfratelli, Palermo; Gaetano Burgio, Istituto Mediterraneo per i Trapianti e Terapia ad alta Specializzazione (IsMeTT), Palermo; Livio Todesco, Civile, Cittadella (PD); Tullio Spina, Civile Spirito Santo, Pescara; Raffaele Zava, San Giovanni Battista e dell’Unione, Foligno (PG); Cinzia Simeoni, Policlinico Monteluce, Perugia; Carlo Mosca, di S. Chiara, Pisa; Massimo Bandini, Misericordia e Dolce, Prato (PO); Cesare Breschi, San Salvatore, Pesaro; Mario Peta, Policlinico San Matteo IRCCS, Pavia; Pierpaolo Casalini, Per gli Infermi, Faenza (RA); Francesco Cosimati, CTO “Andrea Alesini,” ASL RM C, Roma; Danilo Davini, CTO Centro Traumatologico Ospedaliero, Roma; Daniela Alampi, S. Andrea, Roma; Arnaldo Alberti, Casa di Cura “Madonna della Salute,” Porto Viro (RO); Stefania Malengo, S.M. della Misericordia, Rovigo; Stefano Tartari, San Luca, ASL18, Trecenta (RO); Alessandro Mastroianni, Maggiore, Chieri (TO); Paolo Perino, Civile, ASL 6, Cirie’ (TO); Umberto Giuseppe Belloni e Rosa Salcuni, Civile Regione Piemonte, ASL 9, Ivrea (TO); Gilberto Fiore, Santa Croce, Moncalieri (TO); Lorenzo Odetto, S. Luigi Gonzaga, Orbassano (TO); Mauro Pastorelli, Edoardo Agnelli, ASL 10 Regione Piemonte, Pinerolo (TO); Mauro Vacca, CTO Maria Adelaide, Torino; Vincenzo Segala, Mauriziano Umberto I, Torino; Maria Adelaide Arbinolo, San Giovanni Battista, Le Molinette, Torino; Monica Vaj, San Giovanni Battista, Le Molinette, Torino; Enrico Larghero, San Giovanni Battista, Le Molinette, Torino; Marco Vergano, San Giovanni Bosco, Torino; Pietro Roncato, San Giacomo, ASL 8, Castelfranco Veneto (TV); Manuela Lugano, Policlinico Universitario, Udine; Silvano Cominotti, A.O. Ospedale di Circolo e Fondazione Macchi, Varese; Alessandro Deprado, Sant’ Andrea, ASL 11, Vercelli; Flavio Badii, San Donà di Piave, ULSS 10, San Donà di Piave (VE).

Study advisory board (with location in brackets)

Camillo Barbisan (Treviso); Guido Bertolini (Ranica, BG); Ivo Lizzola (Bergamo); Paolo Malacarne (Pisa); Mariano Marchesi (Bergamo); Davide Mazzon (Belluno); Simonetta Spada (Bergamo); Stefano Tomelleri (Bergamo).

Giviti steering committee (with location in brackets)

Guido Bertolini (Ranica, BG); Daniela Boccalatte (Lucca); Paola Cogo (Padova); Maria Giovanna De Cristofaro (Napoli); Emiliano Gamberini (Cesena); Adonella Gorietti (Perugia); Martin Langer (Milano); Nicola Latronico (Brescia); Paolo Malacarne (Pisa); Daniele Poole (Belluno); Danilo Radrizzani (Legnano, MI); Mario Tavola (Lecco); Franco Zuccaro (Matera).

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Bertolini, G., Boffelli, S., Malacarne, P. et al. End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units. Intensive Care Med 36, 1495–1504 (2010). https://doi.org/10.1007/s00134-010-1910-9

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