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      Variation in timing of decisions to withdraw life-sustaining treatment in adult ICU patients from three centres in different geographies: Do clinical factors explain the difference?

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          Abstract

          Background

          Decisions to withdraw life-sustaining treatment (WLST) are common in intensive care units (ICUs). Clinical and non-clinical factors are important, although the extent to which each plays a part is uncertain.

          Objectives

          To determine whether the timing of decisions to WLST varies between ICUs in a single centre in three countries and whether differences in timing are explained by differences in clinical decision-making.

          Methods

          The study involved a convenience sample of three adult ICUs – one in each of the UK, USA and South Africa (SA). Data were prospectively collected on patients whose life-sustaining treatment was withdrawn over three months. The timing of decisions was collected, as were patients’ premorbid functional status and illness severity 24 hours prior to decision to WLST. Multivariate analysis was used to identify factors associated with decisions to WLST. Clinicians participated in interviews involving hypothetical case studies devoid of non-clinical factors.

          Results

          Deaths following WLST accounted for 23% of all deaths during the study period at the USA site v. 37% (UK site) and 70% (SA site) (p<0.0010 across the three sites). Length of stay (LOS) prior to WLST decision varied between sites. Controlling for performance status, age, and illness severity, study site predicted LOS prior to decision (p<0.0010). In the hypothetical cases, LOS prior to WLST was higher for USA clinicians (p<0.017).

          Conclusion

          There is variation in the proportion of ICU patients in whom WLST occurs and the timing of these decisions between sites; differences in clinical decision-making may explain the variation observed, although clinical and non-clinical factors are inextricably linked.

          Contributions of the study

          This study has identified variation in the timing of decisions to withdraw life-sustaining treatment in adult ICUs in three centres in three different healthcare systems. Although differences in clinical decision-making likely explain some of the variation, non-clinical factors (relating to the society in which the clinicians live and work) may also play a part.

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          Most cited references18

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          End-of-life practices in European intensive care units: the Ethicus Study.

          While the adoption of practice guidelines is standardizing many aspects of patient care, ethical dilemmas are occurring because of forgoing life-sustaining therapies in intensive care and are dealt with in diverse ways between different countries and cultures. To determine the frequency and types of actual end-of-life practices in European intensive care units (ICUs) and to analyze the similarities and differences. A prospective, observational study of European ICUs. Consecutive patients who died or had any limitation of therapy. Prospectively defined end-of-life practices in 37 ICUs in 17 European countries were studied from January 1, 1999, to June 30, 2000. Comparison and analysis of the frequencies and patterns of end-of-life care by geographic regions and different patients and professionals. Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%) had limitations of treatments (10% of admissions). Substantial intercountry variability was found in the limitations and the manner of dying: unsuccessful cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range, 0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range, 0%-19%). Shortening of the dying process was reported in 7 countries. Doses of opioids and benzodiazepines reported for shortening of the dying process were in the same range as those used for symptom relief in previous studies. Limitation of therapy vs continuation of life-sustaining therapy was associated with patient age, acute and chronic diagnoses, number of days in ICU, region, and religion (P<.001). The limiting of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors. Although shortening of the dying process is rare, clarity between withdrawing therapies and shortening of the dying process and between therapies intended to relieve pain and suffering and those intended to shorten the dying process may be lacking.
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            Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs.

            To analyze the evolving role, patterns of use, and costs of critical care medicine in the United States from 2000 to 2005. Retrospective study of data from the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, Maryland). Nonfederal, acute care hospitals with critical care medicine beds in the United States. None. None. We analyzed hospital and critical care medicine beds, bed types, days, occupancy rates, payer mix (Medicare and Medicaid), and costs. Critical care medicine costs were compared with national cost indexes. Between 2000 and 2005, the total number of U.S. hospitals with critical care medicine beds decreased by 12.2% (from 3,586 to 3,150). Although the number of hospital beds decreased by 4.2% (from 655,785 to 628,409), both hospital days and occupancy rates increased by 5.1% (from 145.1 to 152.5 million) and 13.7% (from 59% to 67%), respectively. Critical care medicine beds increased by 6.5% (from 88,252 to 93,955), days by 10.6% (from 21.0 to 23.2 million), and occupancy rates by 4.5% (from 65% to 68%). The majority (90%) of critical care medicine beds were classified as intensive care, premature/neonatal, and coronary care unit beds. The percentage of critical care medicine days used by Medicare decreased by 3.8% (from 37.9% to 36.5%) compared with an increase of 15.5% (from 14.5% to 16.8%) by Medicaid. From 2000 to 2005, critical care medicine costs per day increased by 30.4% (from $2698 to $3518). Although annual critical care medicine costs increased by 44.2% (from $56.6 to $81.7 billion), the proportion of hospital costs and national health expenditures allocated to critical care medicine decreased by 1.6% and 1.8%, respectively. However, the proportion of the gross domestic product used by critical care medicine increased by 13.7%. In 2005, critical care medicine costs represented 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of the gross domestic product. Critical care medicine continues to grow in a shrinking U.S. hospital system. The critical care medicine payer mix is evolving, with Medicaid increasing in its percentage of critical care medicine use. Critical care medicine is more cost controlled than other healthcare indexes, but is still using an increasing percentage of the gross domestic product. Our updated and comprehensive critical care medicine use and cost analysis provides a contemporary benchmark for the strategic planning of critical care medicine services within the U.S. healthcare system.
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              International comparisons of intensive care: informing outcomes and improving standards.

              Interest in international comparisons of critical illness is growing, but the utility of these studies is questionable. This review examines the challenges of international comparisons and highlights areas in which international data provide information relevant to clinical practice and resource allocation. International comparisons of ICU resources demonstrate that definitions of critical illness and ICU beds vary due to differences in ability to provide organ support and variable staffing. Despite these limitations, recent international data provide key information to understand the pros and cons of different availability of ICU beds on patient flow and outcomes, and also highlight the need to ensure long-term follow-up due to heterogeneity in discharge practices for critically ill patients. With increasing emphasis on curbing costs of healthcare, systems that deliver lower cost care provide data on alternative options, such as regionalization, flexible allocation of beds, and bed rationing. Differences in provision of critical care can be leveraged to inform decisions on allocation of ICU beds, improve interpretation of clinical outcomes, and assess ways to decrease costs of care. International definitions of key components of critical care are needed to facilitate research and ensure rigorous comparisons.
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                Author and article information

                Journal
                South Afr J Crit Care
                South Afr J Crit Care
                SAJCC
                PMCID
                Southern African Journal of Critical Care
                South African Medical Association (Pretoria, South Africa )
                1562-8264
                2078-676X
                30 July 2020
                2020
                : 36
                : 1
                : 10.7196/SAJCC.2020.v36i1.393
                Affiliations
                [1 ] Imperial School of Anaesthesia, London, UK
                [2 ] Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
                [3 ] Department of Anaesthesia and Perioperative Medicine, Division of Critical Care, University of Cape Town and Groote Schuur Hospital, South Africa
                [4 ] Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
                [5 ] Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
                [6 ] Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
                [7 ] Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pennsylvania, USA
                Author notes
                Correspondence: W H Seligman - seligmanw@ 123456gmail.com

                Declaration: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

                Author Contributions: WHS and SM conceived of the study. WHS was the Chief Investigator. IJ, NS and SM acted as Local PIs in each of the study sites. AC, PH, MF and KBK were responsible for the day-to-day running of the study in each site. AJ and WHS analysed the data and conducted statistical analysis. WHS wrote the first draft, which was subsequently reviewed by all authors.

                Funding: WHS received funding from the Association of Anaesthetists of Great Britain and Ireland, Walter Guinness Trust and British Medical and Dental Students’ Trust which was used to support travel related to the study. The funding bodies did not play any role in the design, conduct or analysis of the study.

                Conflicts of interest: None.

                Author information
                https://orcid.org/0000-0001-6061-7342
                https://orcid.org/0000-0002-3887-2272
                https://orcid.org/0000-0002-3005-5825
                https://orcid.org/0000-0001-9511-5975
                https://orcid.org/0000-0003-2768-0889
                Article
                10.7196/SAJCC.2020.v36i1.393
                10077526
                1856af6f-ff75-4ea5-aae1-4c0ac01bcb08
                Copyright @ 2019

                This is an open-access article distributed under the terms of the Creative Commons Attribution - NonCommercial Works License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 18 December 2019
                Categories
                Research

                intensive care,ethics,withdrawal of life-sustaining treatment

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