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Patients' life-sustaining treatments may be influenced by their ICU

Significant variability in care management is seen across ICUs nationwide with patients who enter the ICU with pre-established end-of-life wishes, according to a recently published study. 

“The variability here is astounding and no matter how hard we tried, we could not make it go away by accounting for any differences among the patients admitted to different ICUs. Surprisingly, for patients who had already outlined ‘I don’t want this or that procedure or treatment at end of life,’ escalations of treatments intensity were nonetheless more common than de-escalations,” Scott Halpern, MD, PhD, MBE, division of Pulmonary, Allergy and Critical Care at the Perelman School of Medicine, University of Pennsylvania, said in a press release. 

Researchers conducted a retrospective cohort study using data from the Project IMPACT database to assess correlation between patients admitted to the ICU who have pre-established life sustaining treatment wishes and the proportion of those patients who receive aggressive care. A total of 277,693 ICU patients from across 140 ICUs in 150 hospitals were enrolled in the study. 

Previously established treatment limitations were found in 4.8% of ICU patients (95% CI, 4.7%-4.9%). Care limitations included prohibiting chest compressions, intubation and electrical cardioversion. These patients were typically older, with a median age of 78 years; 59.4% had dependent care needs and most had preexisting conditions, such as chronic respiratory disease, chronic kidney disease and chronic cardiovascular symptoms.

Patients who survived to hospital discharge were more likely to reverse their care limitations during their ICU stay (17.8%; 95% CI, 17%-18.7%) rather than add new limits (11.7%; 95% CI, 11.1% - 12.4%) (P < .01).

Among patients who entered the ICU with treatment limitations, 23.3% underwent CPR. Of patients with a do not resuscitate order, 24.6% received CPR, and 15.7% of patients who died had CPR. 

When adjusting for risk factors, the amount of patients admitted with treatment limitations varied widely across ICUs (median, 4% range, < 1.0% - 20.9%), along with the number of patients who received CPR (37.7%; 95% CI, 3.8%-92.4%) and new forms of life support (30%; 95% CI, 6%-84.2%). Wide variations were also seen among the proportion of patients that survived ICU stay, who had new treatment limitations established (11.2%; 95% CI, 1.9%-57.3%) and treatment limitation reversals during or following their ICU stay (20.2%; 95% CI, 1.8%-76.2%).

The researchers found no explanation for the reasoning behind the significant variations among ICUs.  

“This tendency toward aggressiveness varies widely depending only on which ICU a patient happens to be admitted to. There seems to be a great potential for better aligning the outcomes of critical care with the outcomes people desire through a better understand of how treatment decisions are made for patients who can and cannot communicate their preferences. We suggest that having clear, effective advance directives along with accompanying conversations with potential surrogate decision makers (usually family) is the best way to prevent unwanted care during an ICU stay,” Hapern said in the release. – by Casey Hower

Disclosure: The researchers report no relevant financial disclosures.