0
Original Research: Critical Care |

Variation in Decisions to Forgo Life-Sustaining Therapies in US ICUsDecisions to Forgo Life-Sustaining Therapies

Caroline M. Quill, MD; Sarah J. Ratcliffe, PhD; Michael O. Harhay, MPH; Scott D. Halpern, MD, PhD
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Dr Quill), Department of Medicine, University of Rochester Medical Center, Rochester, NY; and Fostering Improvement in End-of-Life Decision Science (FIELDS) Program at the Leonard Davis Institute Center for Health Incentives and Behavioral Economics (Drs Quill and Halpern and Mr Harhay), Center for Clinical Epidemiology and Biostatistics (Drs Ratcliffe and Halpern and Mr Harhay), the Division of Pulmonary, Allergy, and Critical Care Medicine (Dr Halpern), and the Department of Medical Ethics and Health Policy (Dr Halpern), Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA.

CORRESPONDENCE TO: Caroline M. Quill, MD, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Box 692, Rochester, NY 14642; e-mail: caroline_quill@urmc.rochester.edu


FOR EDITORIAL COMMENT SEE PAGE 532

FUNDING/SUPPORT: Dr Quill was supported by National Institutes of Health T32HL098054 Training in Critical Care Health Policy Research.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(3):573-582. doi:10.1378/chest.13-2529
Text Size: A A A
Published online

BACKGROUND:  The magnitude and implication of variation in end-of-life decision-making among ICUs in the United States is unknown.

METHODS:  We reviewed data on decisions to forgo life-sustaining therapy (DFLSTs) in 269,002 patients admitted to 153 ICUs in the United States between 2001 and 2009. We used fixed-effects logistic regression to create a multivariable model for DFLST and then calculated adjusted rates of DFLST for each ICU.

RESULTS:  Patient factors associated with increased odds of DFLST included advanced age, female sex, white race, and poor baseline functional status (all P < .001). However, associations with several of these factors varied among ICUs (eg, black race had an OR for DFLST from 0.18 to 2.55 across ICUs). The ICU staffing model was also found to be associated with DFLST, with an open ICU staffing model associated with an increased odds of a DFLST (OR = 1.19). The predicted probability of DFLST varied approximately sixfold among ICUs after adjustment for the fixed patient and ICU effects and was directly correlated with the standardized mortality ratios of ICUs (r = 0.53, 0.41–0.68).

CONCLUSION:  Although patient factors explain much of the variability in DFLST practices, significant effects of ICU culture and practice influence end-of-life decision-making. The observation that an ICU’s risk-adjusted propensity to withdraw life support is directly associated with its standardized mortality ratio suggests problems with using the latter as a quality measure.

Figures in this Article

Sign In to Access Full Content

Want to Purchase a Subscription?

New to CHEST? Become an ACCP member to receive a full subscription to both the print and online editions.
Want to access your Institution's subscription?
Sign in to your individual user account while you are actively authenticated on this website via your institution (Learn more about institutional authentication). We will then sustain your personal access to their content/subscription for 90 days, after which you can repeat this process.

Sign In to Access Full Content

Want to Purchase a Subscription?

New to CHEST? Become an ACCP member to receive a full subscription to both the print and online editions.

Figures

Tables

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
Guidelines
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543