title: End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom.
abstract: OBJECTIVE
  To describe the epidemiology of active treatment withdrawal in a nationally representative cohort of intensive care units (ICUs) focusing on between-unit differences.
  
  
  METHODS
  Cohort study in 127 adult general ICUs in England, Wales and Northern Ireland, 1995 to 2001.
  
  
  METHODS
  118,199 adult admissions to ICUs.
  
  
  RESULTS
  The decision to withdraw all active treatment was made for 11,694 of 118,199 patients (9.9%). There were a total of 36,397 deaths (30.8%) before discharge from hospital, and 11,586 (31.8%) of these occurred after the decision to withdraw active treatment, with no change over time (p=0.54). Considerable variation existed between units regarding the percentage of ICU deaths that occurred after the decision to withdraw active treatment (1.7-96.1%). Median time to death after the decision to withdraw active treatment was 2.4 h; 8% survived more than 24 h. After multilevel modelling, the factors independently associated with the decision to withdraw active treatment were: older age, pre-existing severe medical conditions, emergency surgery or medical admission, cardiopulmonary resuscitation in the 24 h prior to admission, and ventilation or sedation/paralysis in the first 24 h after admission. Substantial between unit variability remained after accounting for case-mix differences in admissions.
  
  
  CONCLUSIONS
  Although we were unable to examine partial withdrawal or withholding of care in this study, we found that the withdrawal of all active treatment is widespread in ICUs in the United Kingdom. There was little change in this practice over the period examined. However, there was considerable variation by unit, even after accounting for patient factors and differences in size and type of ICU, suggesting improved guidelines may be useful to facilitate uniform decision making.
authors.affiliation: Department of Anesthesiology, Columbia University, New York-Presbyterian Hospital, New York, NY 10025, USA.
authors.forename: Hannah
authors.initials: H
authors.lastname: Wunsch
authors.forename: David A
authors.initials: DA
authors.lastname: Harrison
authors.forename: Sheila
authors.initials: S
authors.lastname: Harvey
authors.forename: Kathryn
authors.initials: K
authors.lastname: Rowan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D008020:Life Support Care; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011446:Prospective Studies; D016019:Survival Analysis; D013727:Terminal Care; D006113:United Kingdom / Q000453:epidemiology; D028761:Withholding Treatment