Characterization of limitations of life-sustaining therapy decisions and their impact on outcomes in adults with septic shock - Insights from a retrospective cohort

Abstract

Purpose: In-ICU and in-hospital deaths in critically ill patients are often subsequent to decisions of limitations of life-sustaining therapies (LLST). While septic shock remains associated with high mortality and reduced quality of life in survivors, we addressed the frequency, the decision-making process, the determinants and the attributable mortality of LLST decisions in this setting.

Materials and methods: A retrospective (2008-2021) single-center study including consecutive adult patients with septic shock. LLST were distributed into early and delayed when taken within and after the first three days in the ICU, respectively. Determinants of LLST were assessed by multivariate logistic regression and LLST-attributable mortality was assessed after propensity score matching.

Results: The cohort comprised 907 patients with septic shock. On admission, median SOFA score was 10 [IQR 7-13] points. LLST were decided for 257 (28.3 %) patients after a median of 5 [IQR 2-10] days in the ICU. The first LLST decisions were taken within and after the first three days following ICU admission in 106 and 151 patients, respectively. Independent determinants associated with early LLST decisions were age, disease severity on admission and increasing year of admission. Delayed LLST decisions were significantly associated with comorbidities, duration of organ-support, in-ICU complications and platelet transfusion. The overall in-ICU mortality rate was 37.6 % and reached 75.9 % among patients with LLST.

Conclusion: Among septic shock patients, LLST are frequent, increasingly decided soon after ICU admission, vary during the ICU stay and carry a negative impact on ICU survival.

Keywords: End-of-life; Ethics; Intensive care units; Withdrawing life-sustaining treatments; Withholding life-sustaining treatments; sepsis.