Alexandre Lautrette1,2, Maïté Garrouste-Orgeas3, Pierre-Marie Bertrand4, Dany Goldgran-Toledano5, Samir Jamali6, Virginie Laurent7, Laurent Argaud8, Carole Schwebel9, Bruno Mourvillier10, Michaël Darmon11, Stéphane Ruckly12, Anne-Sylvie Dumenil13, Virginie Lemiale14, Bertrand Souweine4,15, Jean-François Timsit10,12. 1. Medical Intensive Care Unit, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand Cedex 1, France. alautrette@chu-clermontferrand.fr. 2. LMGE (Laboratoire Micro-organismes: Génome et Environnement), UMR CNRS 6023, Clermont-University, Clermont-Ferrand, France. alautrette@chu-clermontferrand.fr. 3. Critical Care Medicine Unit, Saint-Joseph Hospital, Paris, France. 4. Medical Intensive Care Unit, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand Cedex 1, France. 5. Critical Care Medicine Unit, Gonesse Hospital, Gonesse, France. 6. Critical Care Medicine Unit, Dourdan Hospital, Dourdan, France. 7. Critical Care Medicine Unit, Versailles Hospital, Le Chesnay, France. 8. Medical Intensive Care Unit, Edouard Herriot Teaching Hospital, University of Lyon, Lyon, France. 9. Medical Intensive Care Unit, Albert Michallon Teaching Hospital, University Hospital of Grenoble, Grenoble, France. 10. Medical Intensive Care Unit, Bichat-Claude Bernard Teaching Hospital, AP-HP, Paris, France. 11. Medical Intensive Care Unit, Nord Teaching Hospital, University of Saint Etienne, Saint Etienne, France. 12. U823 "Outcome of cancers and critical illness", Albert Bonniot Institute, 38076, La Tronche, France. 13. Surgical Intensive Care Unit, Antoine Beclere University Hospital, Clamart, France. 14. Medical Intensive Care Unit, Saint Louis Teaching Hospital, AP-HP, Paris, France. 15. LMGE (Laboratoire Micro-organismes: Génome et Environnement), UMR CNRS 6023, Clermont-University, Clermont-Ferrand, France.
Abstract
PURPOSE: To assess the prevalence of decisions to forgo life-sustaining treatment (DFLST), the patients characteristics, and to estimate the impact of DFLST stages on mortality. METHODS: Observational study of a prospective database between 2005 and 2012 from 13 ICUs. DFLST were defined as follows: no escalation of treatment (stage 1), not to start or escalate treatment even if such treatment is considered in the future; withholding (stage 2), not to start or escalate necessary treatment; withdrawal (stage 3), to stop necessary treatment. The impact of daily DFLST stage on day-30 hospital mortality was tested with a discrete-time Cox's model and adjusted for admission severity and daily SOFA score. RESULTS: Of 10,080 patients, 1290 (13%) made DFLST. The highest DFLST stage during the ICU stay was no escalation of treatment in 339 (26%) patients, withholding in 502 (39%) patients, and withdrawal in 449 (35%) patients. Older patients, patients with at least one chronic disease, and patients with greater ICU severity were significantly more numerous in the DFLST group. Day-30 mortality was 13% for non-DFLST patients, 35% for no escalation of treatment, 75% for withholding, 93% for withdrawal. After adjustment, an increase in day-30 mortality was associated with withholding and withdrawal (hazard ratio 95% CI 5.93 [4.95-7.12] and 20.05 [15.58-25.79], P < 0.0001), but not with no escalation of treatment (HR 1.14 [0.91-1.44], P = 0.25). CONCLUSIONS: DFLST were made in 13% of ICU patients. Withholding, withdrawal, older age, more comorbidities, and higher severity of illness were associated with higher mortality. No escalation of treatment was not associated with increased mortality.
PURPOSE: To assess the prevalence of decisions to forgo life-sustaining treatment (DFLST), the patients characteristics, and to estimate the impact of DFLST stages on mortality. METHODS: Observational study of a prospective database between 2005 and 2012 from 13 ICUs. DFLST were defined as follows: no escalation of treatment (stage 1), not to start or escalate treatment even if such treatment is considered in the future; withholding (stage 2), not to start or escalate necessary treatment; withdrawal (stage 3), to stop necessary treatment. The impact of daily DFLST stage on day-30 hospital mortality was tested with a discrete-time Cox's model and adjusted for admission severity and daily SOFA score. RESULTS: Of 10,080 patients, 1290 (13%) made DFLST. The highest DFLST stage during the ICU stay was no escalation of treatment in 339 (26%) patients, withholding in 502 (39%) patients, and withdrawal in 449 (35%) patients. Older patients, patients with at least one chronic disease, and patients with greater ICU severity were significantly more numerous in the DFLST group. Day-30 mortality was 13% for non-DFLSTpatients, 35% for no escalation of treatment, 75% for withholding, 93% for withdrawal. After adjustment, an increase in day-30 mortality was associated with withholding and withdrawal (hazard ratio 95% CI 5.93 [4.95-7.12] and 20.05 [15.58-25.79], P < 0.0001), but not with no escalation of treatment (HR 1.14 [0.91-1.44], P = 0.25). CONCLUSIONS:DFLST were made in 13% of ICU patients. Withholding, withdrawal, older age, more comorbidities, and higher severity of illness were associated with higher mortality. No escalation of treatment was not associated with increased mortality.
Authors: Ann C Long; Erin K Kross; Ruth A Engelberg; Lois Downey; Elizabeth L Nielsen; Anthony L Back; J Randall Curtis Journal: Intensive Care Med Date: 2014-08-13 Impact factor: 17.440
Authors: Elie Azoulay; Barbara Metnitz; Charles L Sprung; Jean-François Timsit; François Lemaire; Peter Bauer; Benoît Schlemmer; Rui Moreno; Philipp Metnitz Journal: Intensive Care Med Date: 2008-10-10 Impact factor: 17.440
Authors: Anne Meissner; Kelly Roveran Genga; Fernando Sérgio Studart; Utz Settmacher; Gunther Hofmann; Konrad Reinhart; Yasser Sakr Journal: Crit Care Med Date: 2010-04 Impact factor: 7.598
Authors: Sean M Bagshaw; Neill K J Adhikari; Karen E A Burns; Jan O Friedrich; Josée Bouchard; Francois Lamontagne; Lauralyn A McIntrye; Jean-François Cailhier; Peter Dodek; Henry T Stelfox; Margaret Herridge; Stephen Lapinsky; John Muscedere; James Barton; Donald Griesdale; Mark Soth; Althea Ambosta; Gerald Lebovic; Ron Wald Journal: Clin J Am Soc Nephrol Date: 2019-03-21 Impact factor: 8.237
Authors: John G Laffey; Giacomo Bellani; Tài Pham; Eddy Fan; Fabiana Madotto; Ednan K Bajwa; Laurent Brochard; Kevin Clarkson; Andres Esteban; Luciano Gattinoni; Frank van Haren; Leo M Heunks; Kiyoyasu Kurahashi; Jon Henrik Laake; Anders Larsson; Daniel F McAuley; Lia McNamee; Nicolas Nin; Haibo Qiu; Marco Ranieri; Gordon D Rubenfeld; B Taylor Thompson; Hermann Wrigge; Arthur S Slutsky; Antonio Pesenti Journal: Intensive Care Med Date: 2016-10-18 Impact factor: 17.440
Authors: Bertrand Guidet; Hans Flaatten; Ariane Boumendil; Alessandro Morandi; Finn H Andersen; Antonio Artigas; Guido Bertolini; Maurizio Cecconi; Steffen Christensen; Loredana Faraldi; Jesper Fjølner; Christian Jung; Brian Marsh; Rui Moreno; Sandra Oeyen; Christina Agwald Öhman; Bernardo Bollen Pinto; Ivo W Soliman; Wojciech Szczeklik; Andreas Valentin; Ximena Watson; Tilemachos Zafeiridis; Dylan W De Lange Journal: Intensive Care Med Date: 2018-05-17 Impact factor: 17.440