Variation in Patient Preferences for Life-Sustaining Therapies in the ICU

According to new research from the Perelman School of Medicine at the University of Pennsylvania, intensive care units across the US vary widely in how they care for patients with pre-existing limits on life-sustaining therapies. These include authorizations related to resuscitation, prohibiting interventions such as feeding tubes or dialysis etc. The research has been published in JAMA Internal Medicine.

The study was led by Joanna L. Hart, MD, MSHP, a pulmonary and critical care physician and post-doctoral research fellow at Penn. It is commonly known that end of life and critical care varies across regions and centres but for this research, the study team hypothesised that by specifically focusing on this patient population, they would be able to attribute the variability as an appropriate response to patient preferences. The study team also wanted to determine the portion of ICU patients who were admitted with existing treatment limitations and how they were managed in the ICU.

The research was conducted with 277,693 patients from 141 intensive care units in 105 hospitals from April 2001 to December 2008. The researchers found that 4.8 percent of ICU admissions were patients with pre-existing limits on care. 21 percent of patients had documented restrictions on acceptable therapies ranging from dialysis to nutritional support. 4 percent expressed a preference for comfort measures only. Majority of the patients with treatment limitations were older (78 years on average) and nearly all of them had pre-existing chronic conditions including chronic respiratory disease and chronic kidney disease. 52 percent of the patients were admitted to the ICU from the emergency department. 35 percent of the patients died during the hospital stay studied.

The study findings also show that patients with pre-existing care limitations related to lifesaving measures often changed their preferences during their stay. 23 percent of the patients admitted with treatment limitations received CPR in the ICU. Overall, 41 percent of patients received one or more forms of life support and 18 percent had a reversal of previous treatment limitations during their stay in the ICU. The study indicates that the odds of changes in the pre-existing limitations on care were more likely in ICUs managed by a critical care physician. In addition, odds of changes in treatment limitations were higher in suburban hospitals as compared to urban settings.

According to Scott Halpern, MD, PhD, MBE, assistant professor of Medicine, Epidemiology, and Medical Ethics and Health Policy and the study’s senior author, "This tendency toward aggressiveness varies widely depending only on which ICU a patient happens to be admitted to. There seems to be great potential for better aligning the outcomes of critical care with the outcomes people desire through a better understanding of how treatment decisions are made for patients who can and cannot communicate their preferences. We suggest that having clear, effective advance directives along with accompanying conversations with potential surrogate decision makers (usually family) is the best way to prevent unwanted care during an ICU stay."

Source: Perelman School of Medicine at the University of Pennsylvania

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