Variability Among US Intensive Care Units in Managing the Care of Patients Admitted With Preexisting Limits on Life-Sustaining Therapies

Abstract

Importance: Although the end-of-life care patients receive is known to vary across nations, regions, and centers, these differences are best explored within a group of patients with presumably similar care preferences.

Objective: To examine the proportions of patients admitted to the intensive care unit (ICU) with limitations on life-sustaining treatments and the proportions of such patients who receive aggressive care across individual ICUs.

Design, settings, and participants: Retrospective cohort study using the Project IMPACT database (from April 1, 2001, to December 31, 2008) including 141 ICUs in 105 hospitals in the United States and 277,693 ICU patient visits. We used logistic regression analysis models adjusted for available patient characteristics and clustered visits by individual ICU. The full analysis was last performed in October 2014.

Main outcomes and measures: Outcomes included the provision of (1) cardiopulmonary resuscitation, (2) new forms of life support, and the (3) addition or (4) reversal of treatment limitations.

Results: Of the ICU admissions evaluated, 4.8% (95% CI, 4.7%-4.9%) had previously established treatment limitations. Patients admitted with treatment limitations were more likely to be older with more functional limitations and comorbidities. Among patients who survived to hospital discharge, more experienced reversals of existing treatment limitations during the ICU stay (17.8% [95% CI, 17.0%-18.7%]) than additions of new limits (11.7% [95% CI, 11.1%-12.4%]) (P < .01). Among patients who died, 15.7% (95% CI, 14.7-16.8%) had received cardiopulmonary resuscitation. After risk adjustment, ICUs varied widely in the proportions of patients admitted with treatment limitations (median, 4.0%; range, <1.0%-20.9%), the proportions of those who received cardiopulmonary resuscitation (37.7% [95% CI, 3.8%-92.4%]), the proportions of new forms of life support (30.0% [95% CI, 6.0%-84.2%]), and, among survivors, the proportion who had new treatment limitations established (11.2% [95% CI, 1.9%-57.3%]) and reversal of treatment limitations during or following ICU admission (20.2% [95% CI, 1.8%-76.2%]). The observed variability could not be consistently explained using measurable center-level characteristics.

Conclusions and relevance: Intensive care units vary dramatically in how they manage care for patients admitted with treatment limitations. Among patients who survive, escalations in the aggressiveness of care are more common during the ICU stay than are de-escalations in aggressiveness. This study cannot directly measure whether care received was consistent with patients' preferences but suggests that ICU culture and physicians' practice styles contribute to the aggressiveness of care.

Figure 1. Patient Flowchart

Treatments and outcomes of patients admitted to the intensive care unit (ICU) with preexisting treatment limitations. ^aData were missing for 47 patients.

Figure 2. Variability Among Intensive Care Units (ICUs) in the Management of Patients With Preexisting Limits on Advanced Therapies

All plots represent point estimates and 95% CIs for each included ICU. A, Among 109 ICUs. B, Among 137 ICUs. C, Among 117 ICUs including only survivors of their hospitalization. D, Among 128 ICUs including only survivors of their hospitalization.