Lobo SM, Barros de Simoni FH, Jakob SM, Estella A, Vadi S, Bluethgen A, Martin-Loeches I, Sakr Y, Vincent JL; ICON investigators..; Chest. 2017 May 5. pii: S0012-3692(17)30820-6

BACKGROUND: Many critically ill patients who die will do so after a decision has been made to withhold/withdraw life-sustaining therapy. Our objective was to document the characteristics of intensive care unit (ICU) patients with a decision to withhold/withdraw life-sustaining treatment, including the types of supportive treatments used, patterns of organ dysfunction, and international differences, including gross national income (GNI).

METHODS: In this observational cohort study conducted in 730 ICUs in 84 countries, all adult patients admitted between May 8 and May 18, 2012, except admissions for routine postoperative surveillance, were included.

RESULTS: The analysis included 9,524 patients, with a hospital mortality of 24%. A decision to withhold/withdraw life-sustaining treatment was reported during the ICU stay in 1,259 patients (13%), including 820 (40%) non-survivors and 439 (5%) survivors. Hospital mortality in patients with a decision to withhold/withdraw life-sustaining treatment was 69%. The proportion of deaths in patients with a decision to withhold/withdraw life-sustaining treatment ranged from 10% in South Asia to 67% in Oceania. Decisions to withhold/withdraw life-sustaining treatment were less frequent in low/lower-middle GNI countries than in high GNI countries (6% vs 14%, p<0.001). Greater disease severity, presence of >two organ failures, severe comorbidities, medical and trauma admissions and admission from the emergency room or hospital floor were independent predictors of a decision to withhold/withdraw life-sustaining treatment.

CONCLUSIONS: There is considerable worldwide variability in decisions to withhold/withdraw life-sustaining treatments. Interestingly, almost one-third of patients with a decision to withhold/withdraw life-sustaining treatment left the hospital alive.

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