Withholding or withdrawing invasive interventions may not accelerate time to death among dying ICU patients.

• Main Authors: Daniele Ramazzotti, Peter Clardy, Leo Anthony Celi, David J Stone, Robert S Rudin
• Format: Article
• Language: English
• Published: Public Library of Science (PLoS) 2019-01-01
• Series: PLoS ONE
• Online Access: https://doi.org/10.1371/journal.pone.0212439

<h4>Background</h4>Critically ill patients may die despite invasive intervention. In this study, we examine trends in the application of two such treatments over a decade, namely, endotracheal ventilation and vasopressors and inotropes administration, as well as the impact of these trends on survival durations in patients who die within a month of ICU admission.<h4>Methods</h4>We considered observational data available from the MIMIC-III open-access ICU database and collected within a study period between year 2002 up to 2011. If a patient had multiple admissions to the ICU during the 30 days before death, only the first stay was analyzed, leading to a final set of 6,436 unique ICU admissions during the study period. We tested two hypotheses: (i) administration of invasive intervention during the ICU stay immediately preceding end-of-life would decrease over the study time period and (ii) time-to-death from ICU admission would also decrease, due to the decrease in invasive intervention administration. To investigate the latter hypothesis, we performed a subgroups analysis by considering patients with lowest and highest severity. To do so, we stratified the patients based on their SAPS I scores, and we considered patients within the first and the third tertiles of the score. We then assessed differences in trends within these groups between years 2002-05 vs. 2008-11.<h4>Results</h4>Comparing the period 2002-2005 vs. 2008-2011, we found a reduction in endotracheal ventilation among patients who died within 30 days of ICU admission (120.8 vs. 68.5 hours for the lowest severity patients, p<0.001; 47.7 vs. 46.0 hours for the highest severity patients, p = 0.004). This is explained in part by an increase in the use of non-invasive ventilation. Comparing the period 2002-2005 vs. 2008-2011, we found a reduction in the use of vasopressors and inotropes among patients with the lowest severity who died within 30 days of ICU admission (41.8 vs. 36.2 hours, p<0.001) but not among those with the highest severity. Despite a reduction in the use of invasive interventions, we did not find a reduction in the time to death between 2002-2005 vs. 2008-2011 (7.8 days vs. 8.2 days for the lowest severity patients, p = 0.32; 2.1 days vs. 2.0 days for the highest severity patients, p = 0.74).<h4>Conclusion</h4>We found that the reduction in the use of invasive treatments over time in patients with very poor prognosis did not shorten the time-to-death. These findings may be useful for goals of care discussions.