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Original Research |

Decision-making on withholding or withdrawing life-support in the ICU: A worldwide perspective

Suzana M. Lobo, MD; Flávio Henrique Barros de Simoni, MD; Stephan M. Jakob, MD PhD; Angel Estella, MD; Sonali Vadi, MD; Andreas Bluethgen, MD; Ignacio Martin-Loeches, MD; Yasser Sakr, MD PhD; Jean-Louis Vincent, MD PhD FCCP
Author and Funding Information

The authors have no conflicts of interest to declare

No external financial support

1Intensive Care Division, Medical School, FAMERP, Hospital de Base de S J Rio Preto, Brazil

2Dept of Intensive Care Medicine, University Hospital Bern, University of Bern, Bern, Switzerland

3Intensive Care Unit, Hospital SAS Jerez, Spain

4Department of Critical Care, Global Hospitals, Mumbai, India

5Dept of Intensive Care, Klinikum Augsburg, Augsburg, Germany

6Department of Clinical Medicine, Trinity Centre for Health Sciences, Multidisciplinary Intensive Care Research Organization (MICRO), Wellcome Trust, HRB Clinical Research, St James’s University Hospital Dublin, Dublin, Ireland

7CIBER Enfermedades Respiratorias (CIBERES), Barcelona, Spain

8Dept of Intensive Care, Universitätsklinikum Jena, Jena, Germany

9Dept of Intensive Care, Erasme University Hospital, Unversité Libre de Bruxelles, Brussels, Belgium

Corresponding author: Jean-Louis Vincent Department of Intensive Care Erasme Hospital Route de Lennik 808 1070 Brussels Belgium.


Copyright 2017, . All Rights Reserved.


Chest. 2017. doi:10.1016/j.chest.2017.04.176
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Abstract

Background  Many critically ill patients who die will do so after a decision has been made to withhold/withdraw life-sustaining therapy. Our objective was to document the characteristics of intensive care unit (ICU) patients with a decision to withhold/withdraw life-sustaining treatment, including the types of supportive treatments used, patterns of organ dysfunction, and international differences, including gross national income (GNI).

Methods  In this observational cohort study conducted in 730 ICUs in 84 countries, all adult patients admitted between May 8 and May 18, 2012, except admissions for routine postoperative surveillance, were included.

Results  The analysis included 9,524 patients, with a hospital mortality of 24%. A decision to withhold/withdraw life-sustaining treatment was reported during the ICU stay in 1,259 patients (13%), including 820 (40%) non-survivors and 439 (5%) survivors. Hospital mortality in patients with a decision to withhold/withdraw life-sustaining treatment was 69%. The proportion of deaths in patients with a decision to withhold/withdraw life-sustaining treatment ranged from 10% in South Asia to 67% in Oceania. Decisions to withhold/withdraw life-sustaining treatment were less frequent in low/lower-middle GNI countries than in high GNI countries (6% vs 14%, p<0.001). Greater disease severity, presence of >two organ failures, severe comorbidities, medical and trauma admissions and admission from the emergency room or hospital floor were independent predictors of a decision to withhold/withdraw life-sustaining treatment.

Conclusions  There is considerable worldwide variability in decisions to withhold/withdraw life-sustaining treatments. Interestingly, almost one-third of patients with a decision to withhold/withdraw life-sustaining treatment left the hospital alive.


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