title: Treatment limitations at admission to intensive care units in Australia and New Zealand: prevalence, outcomes, and resource use*.
abstract: BACKGROUND
  Previous studies have addressed patients in whom treatment is withheld or withdrawn after a period of intensive care unit management. However, no studies have investigated the epidemiology of patients with treatment limitations in place at the time of intensive care unit admission.
  
  
  OBJECTIVE
  To report the epidemiology and outcome of patients with treatment limitations at intensive care unit admission and to identify characteristics associated with survival and discharge to home.
  
  
  METHODS
  Retrospective database study using data from the Australian and New Zealand Intensive Care Society Adult Patient Database.
  
  
  METHODS
  Australian and New Zealand intensive care units.
  
  
  METHODS
  One hundred eighty-seven thousand four hundred and one intensive care patients collected over a 3-yr period, 5,989 (3.2%) of whom had treatment limitations at admission to the intensive care unit.
  
  
  METHODS
  Retrospective database study with no interventions. Data collected included patient characteristics, length of stay, mortality, and discharge destination. Mean intensive care unit bed days were used as a surrogate for resource consumption.
  
  
  RESULTS
  Between January 1, 2007, and December 31, 2009, 5,989 (3.2%) patients were reported to the Australia and New Zealand Intensive Care Society Adult Patient Database who had treatment limitation orders at admission to intensive care unit. Mortality was 53% (95% confidence interval 51.7%-54.3%) compared with 9% (95% confidence interval 8.9%-9.1%) in patients admitted for full active management (p ≤ .001). Overall, 30% of patients with treatment limitations were discharged directly to their homes. Intensive care unit bed day usage was similar between the two groups. Within the treatment limitation group, younger patients, those with less comorbid diseases, less acute physiological disturbance, and those admitted following elective surgery, were more likely to survive and be discharged home. Admission diagnosis was an important determinant of outcome with intracranial or subarachnoid hemorrhage predicting a extremely high mortality.
  
  
  CONCLUSIONS
  Patients with treatment limitations on intensive care unit admission comprise approximately 2,000 patients per year in Australia and New Zealand. Despite such limitations, almost half of these patients survive their hospital admission and a third return directly to their home.
authors.affiliation: Department of Intensive CareThe Alfred Hospital, Melbourne, Victoria, Australia. gepgodfrey@yahoo.com
authors.forename: George
authors.initials: G
authors.lastname: Godfrey
authors.forename: David
authors.initials: D
authors.lastname: Pilcher
authors.forename: Andrew
authors.initials: A
authors.lastname: Hilton
authors.forename: Michael
authors.initials: M
authors.lastname: Bailey
authors.forename: Carol L
authors.initials: CL
authors.lastname: Hodgson
authors.forename: Rinaldo
authors.initials: R
authors.lastname: Bellomo
mesh_terms: D018806:APACHE; D000367:Age Factors; D000368:Aged; D001315:Australia / Q000453:epidemiology; D015897:Comorbidity; D016208:Databases, Factual; D017558:Elective Surgical Procedures; D005066:Euthanasia, Passive; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000401:mortality; D006323:Heart Arrest / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007416:Intestinal Perforation / Q000401:mortality; D020300:Intracranial Hemorrhages / Q000401:mortality; D007674:Kidney Diseases / Q000401:mortality; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009520:New Zealand / Q000453:epidemiology; D010343:Patient Admission; D012120:Respiration Disorders / Q000401:mortality; D012189:Retrospective Studies; D012770:Shock, Cardiogenic / Q000401:mortality; D012772:Shock, Septic / Q000401:mortality; D020521:Stroke / Q000401:mortality; D013345:Subarachnoid Hemorrhage / Q000401:mortality; D028761:Withholding Treatment