Bertrand Guidet1,2, Hans Flaatten3,4, Ariane Boumendil5, Alessandro Morandi6,7, Finn H Andersen8,9, Antonio Artigas10, Guido Bertolini11, Maurizio Cecconi12, Steffen Christensen13, Loredana Faraldi14, Jesper Fjølner13, Christian Jung15, Brian Marsh16, Rui Moreno17, Sandra Oeyen18, Christina Agwald Öhman19, Bernardo Bollen Pinto20, Ivo W Soliman21, Wojciech Szczeklik22, Andreas Valentin23, Ximena Watson12, Tilemachos Zafeiridis24, Dylan W De Lange21. 1. Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, 184 rue du Faubourg Saint Antoine, 75012, Paris, France. bertrand.guidet@aphp.fr. 2. Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, 75013, Paris, France. bertrand.guidet@aphp.fr. 3. Department of Clinical Medicine, University of Bergen, Bergen, Norway. 4. Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. 5. Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, 184 rue du Faubourg Saint Antoine, 75012, Paris, France. ariane.boumendil@gmail.com. 6. Department of Rehabilitation, Hospital Ancelle di Cremona, Cremona, Italy. 7. Geriatric Research Group, Brescia, Italy. 8. Department of Anaesthesia and Intensive Care, Ålesund Hospital, Ålesund, Norway. 9. Department of Circulation and Medical Imaging, NTNU, Trondheim, Norway. 10. Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain. 11. Laboratorio di Epidemiologia Clinica, Centro di Coordinamento GiViTI Dipartimento di Salute Pubblica, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri" Villa Camozzi, 24020, Ranica, Bergamo, Italy. 12. St George's University Hospital, London, UK. 13. Department of Anaesthesia and Intensive Care Medicine, Aarhus University Hospital, Åarhus, Denmark. 14. Grande Ospedale Metropolitano Niguarda, Milan, Italy. 15. Department of Cardiology, Pulmonology and Angiology, University Hospital, Düsseldorf, Germany. 16. Mater Misericordiae University Hospital, Dublin, Ireland. 17. Unidade de Cuidados Intensivos Polivalente Neurocríticos, Hospital de São José, Centro Hospitalar de Lisboa Central, Faculdade de Ciência Médicas de Lisboa, Nova Médical School, Lisbon, Portugal. 18. Department of Intensive Care 1K12IC, Ghent University Hospital, Ghent, Belgium. 19. Karolinska University Hospital, Solna, Sweden. 20. Geneva University Hospitals, Geneva, Switzerland. 21. Department of Intensive Care, University Medical Center, University Utrecht, Utrecht, The Netherlands. 22. Intensive Care and Perioperative Medicine Division, Jagiellonian University Medical College, Kraków, Poland. 23. Kardinal Schwarzenberg Hospital, Schwarzach, Austria. 24. Intensive Care Unit General Hospital of Larissa, Larissa, Greece.
Abstract
PURPOSE: To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU. METHODS: This prospective study included intensive care patients aged ≥ 80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up. RESULTS: LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32-7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78-2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12-1.34) and SOFA score [OR of 1.07 (95% CI 1.05-1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries. CONCLUSIONS: The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country. TRIAL REGISTRATION: ClinicalTrials.gov (ID: NTC03134807).
PURPOSE: To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU. METHODS: This prospective study included intensive care patients aged ≥ 80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up. RESULTS: LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32-7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78-2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12-1.34) and SOFA score [OR of 1.07 (95% CI 1.05-1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries. CONCLUSIONS: The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country. TRIAL REGISTRATION: ClinicalTrials.gov (ID: NTC03134807).
Entities:
Keywords:
Elderly; Ethics; Intensive care; Life sustaining treatment; Withdrawal; Withholding
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