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Effect of ICU strain on timing of limitations in life-sustaining therapy and on death

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Abstract

Purpose

The effect of capacity strain in an ICU on the timing of end-of-life decision-making is unknown. We sought to determine how changes in strain impact timing of new do-not-resuscitate (DNR) orders and of death.

Methods

Retrospective cohort study of 9891 patients dying in the hospital following an ICU stay ≥72 h in Project IMPACT, 2001–2008. We examined the effect of ICU capacity strain (measured by standardized census, proportion of new admissions, and average patient acuity) on time to initiation of DNR orders and time to death for all ICU decedents using fixed-effects linear regression.

Results

Increases in strain were associated with shorter time to DNR for patients with limitations in therapy (predicted time to DNR 6.11 days for highest versus 7.70 days for lowest quintile of acuity, p = 0.02; 6.50 days for highest versus 7.77 days for lowest quintile of admissions, p < 0.001), and shorter time to death (predicted time to death 7.64 days for highest versus 9.05 days for lowest quintile of admissions, p < 0.001; 8.28 days for highest versus 9.06 days for lowest quintile of census, only in closed ICUs, p = 0.006). Time to DNR order significantly mediated relationships between acuity and admissions and time to death, explaining the entire effect of acuity, and 65 % of the effect of admissions. There was no association between strain and time to death for decedents without a limitation in therapy.

Conclusions

Strains in ICU capacity are associated with end-of-life decision-making, with shorter times to placement of DNR orders and death for patients admitted during high-strain days.

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Acknowledgments

Dr. Hua is supported by a Mentored-Training Research Grant from the Foundation in Anesthesia Education and Research. Dr. Halpern is supported by a grant from The Otto Haas Charitable Trust. Nicole B. Gabler: None. Dr. Wunsch is supported by Award Number K08AG038477 from the National Institute On Aging.

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street PH5, Room 527D, New York, NY, 10032, USA

    May Hua

  2. Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA

    Scott D. Halpern

  3. Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA

    Scott D. Halpern

  4. Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA

    Scott D. Halpern & Nicole B. Gabler

  5. Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, USA

    Scott D. Halpern & Nicole B. Gabler

  6. Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA

    Scott D. Halpern

  7. Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Canada

    Hannah Wunsch

  8. Department of Anesthesia and Interdisciplinary Department of Critical Care Medicine, University of Toronto, Toronto, Canada

    Hannah Wunsch

  9. Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA

    Hannah Wunsch

Authors
  1. May Hua
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  2. Scott D. Halpern
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  3. Nicole B. Gabler
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  4. Hannah Wunsch
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Corresponding author

Correspondence to May Hua.

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Conflicts of interest

The authors declare that they have no conflict of interest. The funding sources played no role in the design and conduct of the study, collection, management, analysis, and interpretation of the data, or preparation, review, or approval of the manuscript.

Additional information

Take-home message: Increases in ICU strain are associated with shorter time to placement of treatment limitations and shorter time to death for patients dying in the ICU. These data suggest that physicians are capable of performing more efficiently and expediting the delivery of end-of-life care for critically ill patients.

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Hua, M., Halpern, S.D., Gabler, N.B. et al. Effect of ICU strain on timing of limitations in life-sustaining therapy and on death. Intensive Care Med 42, 987–994 (2016). https://doi.org/10.1007/s00134-016-4240-8

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  • DOI: https://doi.org/10.1007/s00134-016-4240-8

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