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. 2014 Sep;146(3):573-582.
doi: 10.1378/chest.13-2529.

Variation in decisions to forgo life-sustaining therapies in US ICUs

Caroline M Quill  1 , Sarah J Ratcliffe  2 , Michael O Harhay  3 , Scott D Halpern  4
Affiliations

Variation in decisions to forgo life-sustaining therapies in US ICUs

Caroline M Quill et al. Chest. 2014 Sep.

Abstract

Background: The magnitude and implication of variation in end-of-life decision-making among ICUs in the United States is unknown.

Methods: We reviewed data on decisions to forgo life-sustaining therapy (DFLSTs) in 269,002 patients admitted to 153 ICUs in the United States between 2001 and 2009. We used fixed-effects logistic regression to create a multivariable model for DFLST and then calculated adjusted rates of DFLST for each ICU.

Results: Patient factors associated with increased odds of DFLST included advanced age, female sex, white race, and poor baseline functional status (all P < .001). However, associations with several of these factors varied among ICUs (eg, black race had an OR for DFLST from 0.18 to 2.55 across ICUs). The ICU staffing model was also found to be associated with DFLST, with an open ICU staffing model associated with an increased odds of a DFLST (OR = 1.19). The predicted probability of DFLST varied approximately sixfold among ICUs after adjustment for the fixed patient and ICU effects and was directly correlated with the standardized mortality ratios of ICUs (r = 0.53, 0.41-0.68).

Conclusion: Although patient factors explain much of the variability in DFLST practices, significant effects of ICU culture and practice influence end-of-life decision-making. The observation that an ICU's risk-adjusted propensity to withdraw life support is directly associated with its standardized mortality ratio suggests problems with using the latter as a quality measure.

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Figures

Figure 1
Figure 1
– Patient flowchart showing the rate and outcome of DFLST among patients in the Project IMPACT database.
Figure 2
Figure 2
– A, Adjusted odds of DFLST for black patients. Each point represents the adjusted odds of a DFLST for black patients in each ICU accompanied by 95% CI. Results stem from fully adjusted models. The reference is white patients. Total number of ICUs is 105 because ICUs with < 5% black patients were excluded from this analysis. B, Adjusted odds of DFLST for patients ≥ 65 years old. Each point represents the adjusted odds of a DFLST for patients ≥ 65 years old in each ICU accompanied by 95% CI. Results stem from fully adjusted models. The reference is age < 65 years. See Figure 1 legend for expansion of abbreviation.
Figure 3
Figure 3
– A, Adjusted predicted probability of DFLST by ICU. The adjusted predicted probability of a DFLST was calculated from the fully adjusted model. The median was 11.5%, with a range from 3.5% to 20.6%. B, Adjusted predicted probability of DFLST by ICU for patients requiring prolonged acute mechanical ventilation (PAMV). The median predicted probability of DFLST among patients requiring PAMV was 32.3%, with a range from 12.3% to 61.7%. See Figure 1 for expansion of other abbreviation.
Figure 4
Figure 4
– Adjusted probability of DFLST by ICU and SMR. The adjusted DFLST rate was directly correlated to the corresponding ICU’s SMR (Pearson’s r, 0.53 [0.41–0.68]; P < .001). SMR = standardized mortality ratio. See Figure 1 for expansion of other abbreviation.
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References

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