Skip to main content
SpringerLink
Log in

End-of-life practices in 282 intensive care units: data from the SAPS 3 database

  • Original
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Objective

To report incidence and characteristics of decisions to forgo life-sustaining therapies (DFLSTs) in the 282 ICUs who contributed to the SAPS3 database.

Methods

We reviewed data on DFLSTs in 14,488 patients. Independent predictors of DFLSTs have been identified by stepwise logistic regression.

Results

DFLSTs occurred in 1,239 (8.6%) patients [677 (54.6%) withholding and 562 (45.4%) withdrawal decisions]. Hospital mortality was 21% (3,050/14,488); 36.2% (1,105) deaths occurred after DFLSTs. Across the participating ICUs, hospital mortality in patients with DFLSTs ranged from 80.3 to 95.4% and time from admission to decisions ranged from 2 to 4 days. Independent predictors of decisions to forgo LSTs included 13 variables associated with increased incidence of DFLSTs and 7 variables associated with decrease incidence of DFLST. Among hospital and ICU-related variables, a higher number of nurses per bed was associated with increased incidence of DFLST, while availability of an emergency department in the same hospital, presence of a full time ICU-specialist and doctors presence during nights and week-ends were associated with a decreased incidence of DFLST.

Conclusion

This large study identifies structural variables that are associated with substantial variations in the incidence and the characteristics of decisions to forgo life-sustaining therapies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

  1. Ruark JE, Raffin TA (1988) Initiating and withdrawing life support. Principles and practice in adult medicine. N Engl J Med 318:25–30

    PubMed  CAS  Google Scholar 

  2. Emanuel EJ (1988) Should physicians withhold life-sustaining care from patients who are not terminally ill? Lancet 1:106–108

    Article  PubMed  CAS  Google Scholar 

  3. Lautrette A, Darmon M, Megarbane B, Joly LM, Chevret S, Adrie C, Barnoud D, Bleichner G, Bruel C, Choukroun G, Curtis JR, Fieux F, Galliot R, Garrouste-Orgeas M, Georges H, Goldgran-Toledano D, Jourdain M, Loubert G, Reignier J, Saidi F, Souweine B, Vincent F, Barnes NK, Pochard F, Schlemmer B, Azoulay E (2007) A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 356:469–478

    Article  PubMed  CAS  Google Scholar 

  4. Pochard F, Azoulay E, Chevret S, Vinsonneau C, Grassin M, Lemaire F, Herve C, Schlemmer B, Zittoun R, Dhainaut JF (2001) French intensivists do not apply American recommendations regarding decisions to forgo life-sustaining therapy. Crit Care Med 29:1887–1892

    Article  PubMed  CAS  Google Scholar 

  5. Prendergast TJ, Claessens MT, Luce JM (1998) A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med 158:1163–1167

    PubMed  CAS  Google Scholar 

  6. Vincent JL (1999) Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med 27:1626–1633

    Article  PubMed  CAS  Google Scholar 

  7. Prendergast TJ, Luce JM (1997) Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med 155:15–20

    PubMed  CAS  Google Scholar 

  8. Cook D, Rocker G, Marshall J, Sjokvist P, Dodek P, Griffith L, Freitag A, Varon J, Bradley C, Levy M, Finfer S, Hamielec C, McMullin J, Weaver B, Walter S, Guyatt G (2003) Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 349:1123–1132

    Article  PubMed  CAS  Google Scholar 

  9. Smedira NG, Evans BH, Grais LS, Cohen NH, Lo B, Cooke M, Schecter WP, Fink C, Epstein-Jaffe E, May C et al (1990) Withholding and withdrawal of life support from the critically ill. N Engl J Med 322:309–315

    PubMed  CAS  Google Scholar 

  10. Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, Ledoux D, Lippert A, Maia P, Phelan D, Schobersberger W, Wennberg E, Woodcock T (2003) End-of-life practices in European intensive care units: the Ethicus Study. JAMA 290:790–797

    Article  PubMed  Google Scholar 

  11. Heyland DK, Cook DJ, Rocker GM, Dodek PM, Kutsogiannis DJ, Peters S, Tranmer JE, O’Callaghan CJ (2003) Decision-making in the ICU: perspectives of the substitute decision-maker. Intensive Care Med 29:75–82

    PubMed  Google Scholar 

  12. Azoulay E, Pochard F, Garrouste-Orgeas M, Moreau D, Montesino L, Adrie C, De Lassence A, Cohen Y, Timsit JF (2003) Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death. Intensive Care Med 29:1895–1901

    Article  PubMed  Google Scholar 

  13. Cook DJ, Guyatt GH, Jaeschke R, Reeve J, Spanier A, King D, Molloy DW, Willan A, Streiner DL (1995) Determinants in Canadian health care workers of the decision to withdraw life support from the critically ill. Canadian Critical Care Trials Group. JAMA 273:703–708

    Article  PubMed  CAS  Google Scholar 

  14. Metnitz PG, Moreno RP, Almeida E, Jordan B, Bauer P, Campos RA, Iapichino G, Edbrooke D, Capuzzo M, Le Gall JR (2005) SAPS 3—from evaluation of the patient to evaluation of the intensive care unit. Part 1: objectives, methods and cohort description. Intensive Care Med 31:1336–1344

    Article  PubMed  Google Scholar 

  15. Moreno RP, Metnitz PG, Almeida E, Jordan B, Bauer P, Campos RA, Iapichino G, Edbrooke D, Capuzzo M, Le Gall JR (2005) SAPS 3—from evaluation of the patient to evaluation of the intensive care unit. Part 2: development of a prognostic model for hospital mortality at ICU admission. Intensive Care Med 31:1345–1355

    Article  PubMed  Google Scholar 

  16. Kramer MS, Feinstein AR (1981) Clinical biostatistics. LIV. The biostatistics of concordance. Clin Pharmacol Ther 29:111–123

    PubMed  CAS  Google Scholar 

  17. Keenan SP, Busche KD, Chen LM, Esmail R, Inman KJ, Sibbald WJ (1998) Withdrawal and withholding of life support in the intensive care unit: a comparison of teaching and community hospitals. The Southwestern Ontario Critical Care Research Network. Crit Care Med 26:245–251

    Article  PubMed  CAS  Google Scholar 

  18. Kollef MH (1996) Private attending physician status and the withdrawal of life-sustaining interventions in a medical intensive care unit population. Crit Care Med 24:968–975

    Article  PubMed  CAS  Google Scholar 

  19. Luce JM, Breeling JL (1988) Critical care practices of chest physicians. Chest 93:163–165

    Article  PubMed  CAS  Google Scholar 

  20. Quill TE, Brody H (1996) Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med 125:763–769

    PubMed  CAS  Google Scholar 

  21. Mebane EW, Oman RF, Kroonen LT, Goldstein MK (1999) The influence of physician race, age, and gender on physician attitudes toward advance care directives and preferences for end-of-life decision-making. J Am Geriatr Soc 47:579–591

    PubMed  CAS  Google Scholar 

  22. Kelly WF, Eliasson AH, Stocker DJ, Hnatiuk OW (2002) Do specialists differ on do-not-resuscitate decisions? Chest 121:957–963

    Article  PubMed  Google Scholar 

  23. Vincent JL (2001) Cultural differences in end-of-life care. Crit Care Med 29:N52–N55

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

Statistical analysis was supported by a grant from the Fund of the Austrian National Bank, Project # 10995 ONB. We thank the participants from all over the world who dedicated a significant amount of their time and effort to this project, proving that it is still possible to conduct a worldwide academic study. A complete list of participants is found in the web-site of the project (http://www.saps3.org).

Author information

Authors and Affiliations

  1. Service de Réanimation Médicale, Hôpital Saint-Louis et Université Paris 7, Assistance Publique, Hôpitaux de Paris, Paris, France

    Élie Azoulay & Benoît Schlemmer

  2. Department of Medical Statistics, University of Vienna, Vienna, Austria

    Barbara Metnitz & Peter Bauer

  3. Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel

    Charles L. Sprung

  4. Medical ICU, Hôpital A. Michallon, BP 217, 38043, Grenoble cedex 9, France

    Jean-François Timsit

  5. Team 11, Outcome of Cancer and Critical Illnesses. UJF-INSERM U823, Centre de Recherche Institut Albert Bonniot, 38706, La Tronche cedex, France

    Jean-François Timsit

  6. Assistance Publique Hop de Paris, Hopital H. Mondor, Paris 12 University, Créteil, France

    François Lemaire

  7. Unidade de Cuidados Intensivos Polivalente, Hospital de St. António dos Capuchos, Centro Hospitalar de Lisboa Central E.P.E, Lisbon, Portugal

    Rui Moreno

  8. Department of Anesthesiology and General Intensive Care, University Hospital of Vienna, Vienna, Austria

    Philipp Metnitz

Authors
  1. Élie Azoulay
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Barbara Metnitz
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Charles L. Sprung
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jean-François Timsit
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. François Lemaire
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Peter Bauer
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Benoît Schlemmer
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Rui Moreno
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Philipp Metnitz
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

on behalf of the SAPS 3 investigators

Corresponding author

Correspondence to Élie Azoulay.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material (DOC 96 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Azoulay, É., Metnitz, B., Sprung, C.L. et al. End-of-life practices in 282 intensive care units: data from the SAPS 3 database. Intensive Care Med 35, 623–630 (2009). https://doi.org/10.1007/s00134-008-1310-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-008-1310-6

Keywords

Search

Navigation