"No Escalation of Treatment" Designations: A Multi-institutional Exploratory Qualitative Study

Area of Science:

• Critical Care Medicine
• Medical Ethics
• Health Services Research

Background:

• No Escalation of Treatment (NoET) designations are utilized in intensive care units (ICUs) globally to restrict treatment for critically ill patients.
• Despite widespread use, NoET designations are debated and have not been previously studied qualitatively.

Purpose of the Study:

• To explore physicians' understanding and perceptions of NoET designations, including their utility and challenges.
• To investigate the mechanisms hospitals employ to facilitate the use of NoET designations.

Main Methods:

• A qualitative study was conducted across seven US hospitals.
• Semistructured interviews were performed with 30 physicians.
• Institutional records, including hospital policies and electronic health record ordering menus, were reviewed.

Main Results:

• Physicians understood NoET to mean withholding new interventions but not stopping ongoing ones.
• Five key functions of NoET were identified: defining treatment limits, aiding in prearrest decompensation, supporting surrogate decision-making, preventing harm, and conserving resources.
• Implementation challenges stemmed from the ambiguous meaning of NoET designations, with only three hospitals having formal designation mechanisms.

Conclusions:

• NoET designations serve important functions in critical care, particularly for end-of-life care, despite ongoing debate.
• Formalizing NoET designation mechanisms and clarifying the meaning of "escalation" are crucial for improving consistency and effectiveness of care.