Reversals and limitations on high-intensity, life-sustaining treatments

Area of Science:

• Critical Care Medicine
• Medical Ethics
• Health Services Research

Background:

• Critically ill patients in the intensive care unit (ICU) often receive high-intensity life-sustaining treatments (LST).
• These treatments can be ineffective and eventually undesired, necessitating careful consideration of treatment goals.
• Understanding factors influencing reversals in LST goals is crucial for informed decision-making.

Purpose of the Study:

• To identify risk factors associated with reversals in life-sustaining treatment goals among critically ill patients.
• To improve understanding of the natural history and epidemiology of critical care.
• To inform clinical decision-making regarding the continuation or limitation of LSTs.

Main Methods:

• A single-institution retrospective cohort study was conducted from 2009 to 2013.
• Electronic medical record data from 10,157 patients receiving LST were analyzed.
• Multivariable Cox regression models assessed associations between patient/clinical factors and subsequent treatment-limiting orders (Comfort Care or do-not-resuscitate [DNR]).

Main Results:

• 8.0% of patients transitioned to Comfort Care, and 16% received new DNR orders.
• Factors associated with transitioning to Comfort Care included older age, cerebrovascular disease, and treatment in Medical ICU or Hematology-Oncology services.
• Older age, female sex, cerebrovascular disease, metastatic cancer, and treatment in specific ICUs were associated with new DNR orders.

Conclusions:

• Reversals or limitations of LST goals occur in over 8% of patients receiving LST.
• These decisions are associated with older female patients, non-ventilator LST, cerebrovascular disease, and care within certain medical specialty services.
• Identifying these associations can aid in better patient and provider understanding of LST trajectories.