ImportanceCritically ill patients often receive high-intensity life sustaining treatments (LST) in the intensive care unit (ICU), although they can be ineffective and eventually undesired. Determining the risk factors associated with reversals in LST goals can improve patient and provider appreciation for the natural history and epidemiology of critical care and inform decision making around the (continued) use of LSTs.MethodsThis is a single institution retrospective cohort study of patients receiving life sustaining treatment in an academic tertiary hospital from 2009 to 2013. Deidentified patient electronic medical record data was collected via the clinical data warehouse to study the outcomes of treatment limiting Comfort Care and do-not-resuscitate (DNR) orders. Extended multivariable Cox regression models were used to estimate the association of patient and clinical factors with subsequent treatment limiting orders.Results10,157 patients received life-sustaining treatment while initially Full Code (allowing all resuscitative measures). Of these, 770 (8.0%) transitioned to Comfort Care (with discontinuation of any life-sustaining treatments) while 1,669 (16%) patients received new DNR orders that reflect preferences to limit further life-sustaining treatment options. Patients who were older (Hazard Ratio(HR) 1.37 [95% CI 1.28–1.47] per decade), with cerebrovascular disease (HR 2.18 [95% CI 1.69–2.81]), treated by the Medical ICU (HR 1.92 [95% CI 1.49–2.49]) and Hematology-Oncology (HR 1.87 [95% CI 1.27–2.74]) services, receiving vasoactive infusions (HR 1.76 [95% CI 1.28, 2.43]) or continuous renal replacement (HR 1.83 [95% CI 1.34, 2.48]) were more likely to transition to Comfort Care. Any new DNR orders were more likely for patients who were older (HR 1.43 [95% CI 1.38–1.48] per decade), female (HR 1.30 [95% CI 1.17–1.44]), with cerebrovascular disease (HR 1.45 [95% CI 1.25–1.67]) or metastatic solid cancers (HR 1.92 [95% CI 1.48–2.49]), or treated by Medical ICU (HR 1.63 [95% CI 1.42–1.86]), Hematology-Oncology (HR 1.63 [95% CI 1.33–1.98]) and Cardiac Care Unit-Heart Failure (HR 1.41 [95% CI 1.15–1.72]).ConclusionDecisions to reverse or limit treatment goals occurs after more than 1 in 13 trials of LST, and is associated with older female patients, receiving non-ventilator forms of LST, cerebrovascular disease, and treatment by certain medical specialty services.

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Background:There is a clear need for orthopaedic-specific protocols to minimize the risks of prolonged opioid use after surgery. The authors assessed the effect of an opioid-prescribing protocol on new persistent opioid use in patients who were treated surgically for fractures. The hypothesis of this study was that the protocol would reduce the rate of new persistent opioid use. Methods:The study cohort consisted of patients who were treated at a level 1 trauma center before and after implementation of an opioid prescribing protocol. One hundred twenty-two patients prior to protocol implementation and 103 patients after protocol implementation met inclusion criteria. The primary outcome measured was persistent opioid use more than 6 mo postoperatively. Results:There was a significant decrease in the rate of new persistent opioid use in the protocol group from 25% to 12%. The number of patients who needed to be treated to prevent one case of new persistent opioid use was eight. Age was a significant risk factor for new persistent opioid use. For each additional year in age, risk increased by 3%. Conclusions:The authors studied the effect of implementing a protocol for prescribing opioids at a Level 1 trauma center and found a statistically and clinically significant decrease in the rate of new persistent opioid use after implementation of the protocol. Increasing age was identified as an independent risk factor for new persistent opioid use.