Date Published: July 18, 2017
Publisher: Public Library of Science
Author(s): Stein Arve Skjaker, Henrik Hoel, Vegard Dahl, Knut Stavem, Yu Ru Kou.
Few previous studies have investigated associations between clinical variables available after 24 hours in the intensive care unit (ICU), including the Charlson Comorbidity Index (CCI), and decisions to restrict life-sustaining treatment. The aim of this study was to identify factors associated with the life-sustaining treatment restriction and to explore if CCI contributes to explaining decisions to restrict life-sustaining treatment in the ICU at a university hospital in Norway from 2007 to 2009.
Patients’ Simplified Acute Physiology Score II (SAPS II), age, sex, type of admission, and length of hospital stay prior to being admitted to the unit were recorded. We retrospectively registered the CCI for all patients based on the medical records prior to the index stay. A multivariable logistic regression analysis was used to assess factors associated with treatment restriction during the ICU stay.
We included 936 patients, comprising 685 (73%) medical, 204 (22%) unscheduled and 47 (5%) scheduled surgical patients. Treatment restriction was experienced by 241 (26%) patients during their ICU stay. The variables that were significantly associated with treatment restriction in multivariable analysis were older age (odds ratio [OR] = 1.48 per 10 years, 95% confidence interval [CI] = 1.28–1.72 per 10 years), higher SAPS II (OR = 1.05, 95% CI = 1.04–1.07) and CCI values relative to the reference of CCI = 0: CCI = 2 (OR = 2.08, 95% CI = 1.20–3.61) and CCI≥3 (OR = 2.72, 95% CI = 1.65–4.47).
In multivariable analysis, older age, greater illness severity after 24 h in the ICU and greater comorbidity at hospital admission were independently associated with subsequent life-sustaining treatment restriction. The CCI score contributed additional information independent of the SAPS II illness severity rating.
Increasing therapeutic possibilities have made decisions to withhold or withdraw life-sustaining treatments in intensive care units (ICUs) more common [1–3]. Many patients who have treatment withheld or withdrawn die during their hospital stay , and most of the deaths in the ICU occur after such decisions are taken [3, 5, 6]. It is therefore important to understand if information available during the initial period of the ICU stay is associated with later decisions to withhold or withdraw life-sustaining treatment.
In this study, patients were more likely to experience treatment restriction if they were older, had a more severe acute illness at ICU admission, or had more severe comorbidity as assessed by CCI at hospital admission. Also, patients with a metabolic principal disease category were less likely to experience treatment restriction during their ICU stay.
In this study we found that older age, greater illness severity after 24 h in the ICU and greater comorbidity at hospital admission were independently associated with life-sustaining treatment restriction. The CCI score contributed additional information independent of the illness severity rating.