title: Defining the practice of "no escalation of care" in the ICU.
abstract: OBJECTIVE
  Withdrawal or withholding of life-sustaining therapies precedes most deaths in the modern ICU. As goals of care for critically ill patients change from curative to palliative, this transition often occurs abruptly, but a slower more staggered approach may also be used. One such approach is "no escalation of care", often the first step in this transition at the end-of-life. We aimed to determine the prevalence of no escalation of care designation for ICU decedents and identify which interventions are involved.
  
  
  METHODS
  We performed a retrospective medical record review of all patients who died over a two year period. Records with documentation of no escalation of care in physician orders or progress notes, or other instructions suggesting sequential or selective limitation of interventions were included.
  
  
  METHODS
  Sixteen bed medical ICU at a single large academic hospital.
  
  
  METHODS
  None.
  
  
  RESULTS
  Of a total of 310 ICU decedents, 95 (30%) had a no escalation of care designation before death. Hemodialysis, vasopressors, and blood transfusions were the interventions more likely to be withheld. For ongoing therapies, hemodialysis, blood transfusions, and antibiotics were more likely to be withdrawn. Mechanical ventilation, hydration, and nutrition were less likely to be withheld or withdrawn. A minority had a palliative care consult (15%) or ethics consult (4%) while in the ICU. Time from no escalation of care designation to death averaged 0.8 days (range, 0-5 d).
  
  
  CONCLUSIONS
  No escalation of care designation occurs in a significant proportion of ICU decedents shortly before death. Some interventions are more likely to be limited than others using a no escalation of care approach.
authors.affiliation: 1Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX. 2Section of General Internal Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC. 3Department of Pediatrics, Center for Clinical Research and Evidence-Based Medicine, University of Texas Health Science Center at Houston, Houston, TX.
authors.forename: Christopher K
authors.initials: CK
authors.lastname: Morgan
authors.forename: Grace M
authors.initials: GM
authors.lastname: Varas
authors.forename: Claudia
authors.initials: C
authors.lastname: Pedroza
authors.forename: Khalid F
authors.initials: KF
authors.lastname: Almoosa
mesh_terms: D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008020:Life Support Care / Q000592:standards*; D008297:Male; D008875:Middle Aged; D016079:Refusal to Treat; D012189:Retrospective Studies; D013727:Terminal Care / Q000592:standards*