No Escalation of Treatment (NoET) designations are used in ICUs to limit treatment for critically ill patients. However, they are the subject of much debate and have not been qualitatively studied.

In this study conducted at seven hospitals in the U.S., researchers evaluate how physicians understand and perceive NoET designations with regard to their utility and associated challenges. They also explore what mechanisms hospitals provide to facilitate the use of NoET designations. Semi-structured interviews were conducted with thirty physicians. In addition, there was a review of relevant institutional records such as hospital policies, screenshots of ordering menus in the electronic health record etc.

As per the analysis, study participants reported using NoET designations, which they understood to mean that providers should withhold new or higher-intensity interventions (escalation) but not withdraw ongoing ones. Three hospitals provided a specific mechanism for designating a patient as NoET (e.g., a DNR/Do-Not-Escalate code status order). The remaining hospitals used various informal methods (e.g., verbal handoffs).

Five functions of NoET designations were identified:

  1. Defining an intermediate point of treatment limitation.
  2. Helping physicians navigate pre-arrest clinical decompensations.
  3. Helping surrogate decision-makers transition towards comfort care.
  4. Preventing patient harm from invasive measures.
  5. Conserving critical care resources.

Study participants reported implementation challenges related to the ambiguity in the meaning of NoET designations.

These findings show that NoET designations are used in various hospitals and are believed to have multiple functions. In other words, NoET designations fulfill an essential need in the care of critically ill patients, especially at the end of life. However, their use can be improved by implementing a formal mechanism that promotes consistency across providers and clarifies explicitly the meaning of escalation for each patient.

Source: Chest

Image Credit: iStock 


Batten JN, Blythe JA, Wieten SE et al. (2022) "No Escalation of Treatment" Designations: A Multi-Institutional Exploratory Qualitative Study. Chest. S0012-3692(22)03679-0. 

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