Derivation and performance of an end-of-life practice score aimed at interpreting worldwide treatment-limiting decisions in the critically ill

Abstract

Background Limitations of life-sustaining interventions in intensive care units (ICUs) exhibit substantial changes over time, and large, contemporary variation across world regions. We sought to determine whether a weighted end-of-life practice score can explain a large, contemporary, worldwide variation in limitation decisions. Methods The 2015–2016 (Ethicus-2) vs. 1999–2000 (Ethicus-1) comparison study was a two-period, prospective observational study assessing the frequency of limitation decisions in 4952 patients from 22 European ICUs. The worldwide Ethicus-2 study was a single-period prospective observational study assessing the frequency of limitation decisions in 12,200 patients from 199 ICUs situated in 8 world regions. Binary end-of-life practice variable data (1 = presence; 0 = absence) were collected post hoc (comparison study, 22/22 ICUs, n = 4592; worldwide study, 186/199 ICUs, n = 11,574) for family meetings, daily deliberation for appropriate level of care, end-of-life discussions during weekly meetings, written triggers for limitations, written ICU end-of-life guidelines and protocols, palliative care and ethics consultations, ICU-staff taking communication or bioethics courses, and national end-of-life guidelines and legislation. Regarding the comparison study, generalized estimating equations (GEE) analysis was used to determine associations between the 12 end-of-life practice variables and treatment limitations. The weighted end-of-life practice score was then calculated using GEE-derived coefficients of the end-of-life practice variables. Subsequently, the weighted end-of-life practice score was validated in GEE analysis using the worldwide study dataset. Results In comparison study GEE analyses, end-of-life discussions during weekly meetings [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.30–0.99], end-of-life guidelines [OR 0.52, (0.31–0.87)] and protocols [OR 15.08, (3.88–58.59)], palliative care consultations [OR 2.63, (1.23–5.60)] and end-of-life legislation [OR 3.24, 1.60–6.55)] were significantly associated with limitation decisions (all P < 0.05). In worldwide GEE analyses, the weighted end-of-life practice score was significantly associated with limitation decisions [OR 1.12 (1.03–1.22); P = 0.008]. Conclusions Comparison study-derived, weighted end-of-life practice score partly explained the worldwide study’s variation in treatment limitations. The most important components of the weighted end-of-life practice score were ICU end-of-life protocols, palliative care consultations, and country end-of-life legislation.

Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study

“…International differences in practices of LST limitation are striking [ 2 , 3 ]. Considering all ICU patients, the proportion with LST limitation in our study (19.2%) was higher than the international average of 11.8% seen in the ETHICUS-2 study which surveyed 199 ICUs in 36 countries in 2015 and 2016 and the international average of 13.2% seen in the Intensive Care Over Nations (ICON) study which surveyed 730 ICUs in 84 countries in 2012 [ 15 , 16 ].…”

“…Decisions to limit life-sustaining treatments (LST), through withholding or withdrawing are commonly made in the intensive care unit (ICU) [ 1 ]. Despite recommendations by several critical care societies, there remains substantial variation in the practices surrounding LST limitations [ 2 ]. These decisions may be influenced by factors including age and pre-existing severe comorbidities, severity of the acute illness and sociocultural beliefs [ 3 ].…”

Standardized High-Quality Processes for End-of-Life-Decision Making in the Intensive Care Unit Remain Robust during an Unprecedented New Pandemic—A Single-Center Experience

“…Like reported from multiple other studies, deceased patients with COVID-19 were more frequently male, had a longer ICU-LOS, and received more ICU organ replacement and support therapy than non-COVID-19 patients [ 23 , 24 ]. High-quality end-of-life practice is associated with ICU end-of-life protocols and country end-of-life legislation [ 25 ]. Like many other European countries, German legislation guides and supports EOLD processes and the use of advance care planning [ 1 , 5 ].…”

Triggers of intensive care patients with palliative care needs from nurses’ perspective: a mixed methods study

“…Palliative care teams focus on symptom relief, effective communication about treatment goals, alignment of treatment with patients’ preferences, family support and care planning [ 5 ]. Co-treatment by multiprofessional sPC teams therefore is an appropriate option for ICU patients and can also be offered in conjunction with life-prolonging treatments and especially in collaboration with ICU teams [ 10 – 12 ]. Timely integration of palliative care can complement counselling, treatment and support for relatives and patients, which can lead to improved quality of life and satisfaction for both [ 13 ].…”