Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal.
OBJECTIVE
To assess decisions to forego life-sustaining treatment (LST) in patients too sick for intensive care unit (ICU) admission, comparatively to patients admitted to the ICU.


METHODS
Prospective observational cohort study.


METHODS
A medical-surgical ICU.


METHODS
Consecutive patients referred to the ICU during a one-yr period.


METHODS
None.


RESULTS
Of 898 triaged patients, 147 were deemed too well to benefit from ICU admission. Decisions to forego LST were made in 148 of 666 (22.2%) admitted patients and in all 85 patients deemed too sick for ICU admission. Independent predictors of decisions to forego LST at ICU refusal rather than after ICU admission were: age; underlying disease; living in an institution; preexisting cognitive impairment; admission for medical reasons; and acute cardiac failure, acute central neurologic illness, or sepsis. Hospital mortality after decisions to forego LST was not significantly different in refused and admitted patients (77.5% vs. 86.5%; p = .1). Decisions to forego LST were made via telephone in 58.8% of refused patients and none of the admitted patients. Nurses caring for the patient had no direct contact with the ICU physicians for 62.3% of the decisions in refused patients, whereas meetings between nurses and physicians occurred in 70.3% of decisions to forego LST in the ICU. Patients or relatives were involved in 28.2% of decisions to forego LST at ICU refusal compared with 78.4% of decisions to forego LST in ICU patients (p < .001).


CONCLUSIONS
All patients deemed too sick for ICU admission had decisions to forego LST. These decisions were made without direct patient examination in two-thirds of refused patients (vs. none of admitted patients) and were associated with less involvement of nurses and relatives compared with decisions in admitted patients. Further work is needed to improve decisions to forego LST made under the distinctive circumstances of triage.
Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France. jean.reignier@chd-vendee.fr
Jean
J
Reignier
Romain
R
Dumont
Sandrine
S
Katsahian
Laurent
L
Martin-Lefevre
Benoit
B
Renard
Maud
M
Fiancette
Christine
C
Lebert
Eva
E
Clementi
Frederic
F
Bontemps
D003422:Critical Care / Q000941:ethics / Q000523:psychology*; D003657:Decision Making; D005260:Female; D005602:France; D006801:Humans; D007362:Intensive Care Units; D008020:Life Support Care / Q000523:psychology*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016079:Refusal to Treat / Q000941:ethics / Q000706:statistics & numerical data*; D016312:Treatment Refusal / Q000523:psychology / Q000706:statistics & numerical data*; D014218:Triage / Q000706:statistics & numerical data*