Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Mar 11;27(1):103.
doi: 10.1186/s13054-023-04349-1.

Limitation of life-sustaining therapies in critically ill patients with COVID-19: a descriptive epidemiological investigation from the COVID-ICU study

Mikhael Giabicani #  1   2 , Christophe Le Terrier #  3 , Antoine Poncet  4   5 , Bertrand Guidet  6 , Jean-Philippe Rigaud  7 , Jean-Pierre Quenot  8 , Marie-France Mamzer  2   9 , Jérôme Pugin  3 , Emmanuel Weiss  1 , Simon Bourcier  10 ; COVID-ICU study investigators
Collaborators, Affiliations

Limitation of life-sustaining therapies in critically ill patients with COVID-19: a descriptive epidemiological investigation from the COVID-ICU study

Mikhael Giabicani et al. Crit Care. .

Abstract

Background: Limitations of life-sustaining therapies (LST) practices are frequent and vary among intensive care units (ICUs). However, scarce data were available during the COVID-19 pandemic when ICUs were under intense pressure. We aimed to investigate the prevalence, cumulative incidence, timing, modalities, and factors associated with LST decisions in critically ill COVID-19 patients.

Methods: We did an ancillary analysis of the European multicentre COVID-ICU study, which collected data from 163 ICUs in France, Belgium and Switzerland. ICU load, a parameter reflecting stress on ICU capacities, was calculated at the patient level using daily ICU bed occupancy data from official country epidemiological reports. Mixed effects logistic regression was used to assess the association of variables with LST limitation decisions.

Results: Among 4671 severe COVID-19 patients admitted from February 25 to May 4, 2020, the prevalence of in-ICU LST limitations was 14.5%, with a nearly six-fold variability between centres. Overall 28-day cumulative incidence of LST limitations was 12.4%, which occurred at a median of 8 days (3-21). Median ICU load at the patient level was 126%. Age, clinical frailty scale score, and respiratory severity were associated with LST limitations, while ICU load was not. In-ICU death occurred in 74% and 95% of patients, respectively, after LST withholding and withdrawal, while median survival time was 3 days (1-11) after LST limitations.

Conclusions: In this study, LST limitations frequently preceded death, with a major impact on time of death. In contrast to ICU load, older age, frailty, and the severity of respiratory failure during the first 24 h were the main factors associated with decisions of LST limitations.

Keywords: Acute respiratory distress syndrome; COVID-19; Critical care; Ethical; Life-sustaining therapy; Outcome.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flowchart of study population
Fig. 2
Fig. 2
A Cumulative incidence plot of time from ICU admission to first LST limitation decision, and B survival probability after LST withholding or withdrawing decisions within 14 days after ICU admission
Fig. 3
Fig. 3
Distribution of estimated prevalence of life-sustaining treatment limitations according to centres
See this image and copyright information in PMC

Comment in

References

    1. Clinical characteristics and day-90 outcomes of 4244 critically ill adults with COVID-19: a prospective cohort study. Intensive Care Med. 2020;1–14. - PMC - PubMed
    1. Qian Z, Alaa AM, van der Schaar M, Ercole A. Between-centre differences for COVID-19 ICU mortality from early data in England. Intensive Care Med. 2020;46:1779–1780. doi: 10.1007/s00134-020-06150-y. - DOI - PMC - PubMed
    1. Taccone FS, Vangoethem N, Depauw R, Wittebole X, Blot K, Vanoyen H, et al. The role of organizational characteristics on the outcome of COVID-19 patients admitted to the ICU in Belgium. The Lancet Regional Health-Europe. 2020;100019. - PMC - PubMed
    1. Bravata DM, Perkins AJ, Myers LJ, Arling G, Zhang Y, Zillich AJ, et al. Association of intensive care unit patient load and demand with mortality rates in us department of veterans affairs hospitals during the COVID-19 pandemic. JAMA Netw Open. 2021;4:e2034266. doi: 10.1001/jamanetworkopen.2020.34266. - DOI - PMC - PubMed
    1. Rimmelé T, Pascal L, Polazzi S, Duclos A. Organizational aspects of care associated with mortality in critically ill COVID-19 patients. Intensive Care Med. 2021;47:119–121. doi: 10.1007/s00134-020-06249-2. - DOI - PMC - PubMed