. 2016 Jun;42(6):987-94.

doi: 10.1007/s00134-016-4240-8. Epub 2016 Feb 9.

Effect of ICU strain on timing of limitations in life-sustaining therapy and on death

May Hua¹, Scott D Halpern^{2

3

4

5

6}, Nicole B Gabler^{4

5}, Hannah Wunsch^{7

8

9}

Affiliations

¹ Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street PH5, Room 527D, New York, NY, 10032, USA. mh2633@cumc.columbia.edu.
² Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
³ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA.
⁴ Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
⁵ Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, USA.
⁶ Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
⁷ Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Canada.
⁸ Department of Anesthesia and Interdisciplinary Department of Critical Care Medicine, University of Toronto, Toronto, Canada.
⁹ Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA.

PMID: 26862018
PMCID: PMC4846491
DOI: 10.1007/s00134-016-4240-8

Effect of ICU strain on timing of limitations in life-sustaining therapy and on death

May Hua et al. Intensive Care Med. 2016 Jun.

. 2016 Jun;42(6):987-94.

doi: 10.1007/s00134-016-4240-8. Epub 2016 Feb 9.

Authors

May Hua¹, Scott D Halpern^{2

3

4

5

6}, Nicole B Gabler^{4

5}, Hannah Wunsch^{7

8

9}

Affiliations

¹ Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street PH5, Room 527D, New York, NY, 10032, USA. mh2633@cumc.columbia.edu.
² Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
³ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA.
⁴ Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
⁵ Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, USA.
⁶ Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
⁷ Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Canada.
⁸ Department of Anesthesia and Interdisciplinary Department of Critical Care Medicine, University of Toronto, Toronto, Canada.
⁹ Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA.

PMID: 26862018
PMCID: PMC4846491
DOI: 10.1007/s00134-016-4240-8

Abstract

Purpose: The effect of capacity strain in an ICU on the timing of end-of-life decision-making is unknown. We sought to determine how changes in strain impact timing of new do-not-resuscitate (DNR) orders and of death.

Methods: Retrospective cohort study of 9891 patients dying in the hospital following an ICU stay ≥72 h in Project IMPACT, 2001-2008. We examined the effect of ICU capacity strain (measured by standardized census, proportion of new admissions, and average patient acuity) on time to initiation of DNR orders and time to death for all ICU decedents using fixed-effects linear regression.

Results: Increases in strain were associated with shorter time to DNR for patients with limitations in therapy (predicted time to DNR 6.11 days for highest versus 7.70 days for lowest quintile of acuity, p = 0.02; 6.50 days for highest versus 7.77 days for lowest quintile of admissions, p < 0.001), and shorter time to death (predicted time to death 7.64 days for highest versus 9.05 days for lowest quintile of admissions, p < 0.001; 8.28 days for highest versus 9.06 days for lowest quintile of census, only in closed ICUs, p = 0.006). Time to DNR order significantly mediated relationships between acuity and admissions and time to death, explaining the entire effect of acuity, and 65 % of the effect of admissions. There was no association between strain and time to death for decedents without a limitation in therapy.

Conclusions: Strains in ICU capacity are associated with end-of-life decision-making, with shorter times to placement of DNR orders and death for patients admitted during high-strain days.

Keywords: Critical care; Decision-making; End-of-life care; Palliative care.

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Conflict of interest statement

May Hua reported no conflicts of interest.

Scott Halpern reported no conflicts of interest.

Nicole Gabler reported no conflicts of interest.

Hannah Wunsch reported no conflicts of interest.

Figures

**Fig. 1. Conceptual model of mediation analysis**
ICU strain affects time to death directly (τ’), as well as through an indirect path that is mediated by time to DNR. The direct effect of ICU strain on time to death is equal to the coefficient τ’, while the indirect effect of ICU strain on time to death is equal to αβ. The presence of a significant indirect effect is suggestive of mediation, or that time to DNR plays a causal role in the effect of ICU strain on time to death

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Comment in

Intensive care unit strain should not rush physicians into making inappropriate decisions, but merely reduce the time to the right decisions being made.
Quenot JP, Ecarnot F, Meunier-Beillard N, Dargent A, Large A, Andreu P, Rigaud JP. Quenot JP, et al. Ann Transl Med. 2016 Aug;4(16):316. doi: 10.21037/atm.2016.07.27. Ann Transl Med. 2016. PMID: 27668236 Free PMC article. No abstract available.

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Effect of ICU strain on timing of limitations in life-sustaining therapy and on death

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Effect of ICU strain on timing of limitations in life-sustaining therapy and on death

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