End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units.
OBJECTIVE
To appraise the end-of-life decision-making in several intensive care units (ICUs) and to evaluate the association between the average inclination to limit treatment and overall survival at ICU level.


METHODS
Prospective, multicenter, observational study, lasting 12 months.


METHODS
Eighty-four Italian, adult ICUs.


METHODS
Consecutive patients (3,793) who died in ICU or were discharged in terminal condition, in 2005.


METHODS
Data collection included patient description, treatment limitation and decision-makers, involvement of patients and relatives in the decision, and organ donation. A logistic regression model was used to identify predictors of treatment limitation and develop a measure of the inclination to limit treatment for each ICU. This was compared with the standardized mortality ratio, an index of the overall performance of the unit.


RESULTS
Treatment limitation preceded 62% of deaths. In 25% of cases, nurses were involved in the decision. Half the limitations were do-not-resuscitate orders, with the remaining half almost equally split between withholding and withdrawing treatment. Units less inclined to limit treatments (odds ratio <0.77) showed higher overall standardized mortality ratio (1.08; 95% confidence interval: 1.04-1.12).


CONCLUSIONS
The voluntary nature of participation, with self-selected ICUs from a self-selected independent network.


CONCLUSIONS
Treatment limitation is common in ICU and still principally a physician's responsibility. Units with below-average inclination to limit treatments have worse performance in terms of overall mortality, showing that limitation is not against the patient's interests. On the contrary, the inclination to limit treatments at the end of life can be taken as an indication of quality in the unit.
Bertolini
Guido
G
Laboratorio di Epidemiologia Clinica, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò, Istituto di Ricerche Farmacologiche Mario Negri, 24020, Ranica, BG, Italy. bertolini@marionegri.it
Boffelli
Simona
S
Malacarne
Paolo
P
Peta
Mario
M
Marchesi
Mariano
M
Barbisan
Camillo
C
Tomelleri
Stefano
S
Spada
Simonetta
S
Satolli
Roberto
R
Gridelli
Bruno
B
Lizzola
Ivo
I
Mazzon
Davide
D
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003422:Critical Care / Q000706:statistics & numerical data; D016638:Critical Illness / Q000401:mortality* / Q000628:therapy; D003657:Decision Making; D005066:Euthanasia, Passive / Q000706:statistics & numerical data; D005195:Family Relations; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D007558:Italy / Q000453:epidemiology; D008020:Life Support Care / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016414:Resuscitation Orders; D028761:Withholding Treatment / Q000706:statistics & numerical data*; D055815:Young Adult
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