title: Variability Among US Intensive Care Units in Managing the Care of Patients Admitted With Preexisting Limits on Life-Sustaining Therapies.
abstract: OBJECTIVE
  Although the end-of-life care patients receive is known to vary across nations, regions, and centers, these differences are best explored within a group of patients with presumably similar care preferences.
  
  
  OBJECTIVE
  To examine the proportions of patients admitted to the intensive care unit (ICU) with limitations on life-sustaining treatments and the proportions of such patients who receive aggressive care across individual ICUs.
  
  
  METHODS
  Retrospective cohort study using the Project IMPACT database (from April 1, 2001, to December 31, 2008) including 141 ICUs in 105 hospitals in the United States and 277,693 ICU patient visits. We used logistic regression analysis models adjusted for available patient characteristics and clustered visits by individual ICU. The full analysis was last performed in October 2014.
  
  
  METHODS
  Outcomes included the provision of (1) cardiopulmonary resuscitation, (2) new forms of life support, and the (3) addition or (4) reversal of treatment limitations.
  
  
  RESULTS
  Of the ICU admissions evaluated, 4.8% (95% CI, 4.7%-4.9%) had previously established treatment limitations. Patients admitted with treatment limitations were more likely to be older with more functional limitations and comorbidities. Among patients who survived to hospital discharge, more experienced reversals of existing treatment limitations during the ICU stay (17.8% [95% CI, 17.0%-18.7%]) than additions of new limits (11.7% [95% CI, 11.1%-12.4%]) (P < .01). Among patients who died, 15.7% (95% CI, 14.7-16.8%) had received cardiopulmonary resuscitation. After risk adjustment, ICUs varied widely in the proportions of patients admitted with treatment limitations (median, 4.0%; range, <1.0%-20.9%), the proportions of those who received cardiopulmonary resuscitation (37.7% [95% CI, 3.8%-92.4%]), the proportions of new forms of life support (30.0% [95% CI, 6.0%-84.2%]), and, among survivors, the proportion who had new treatment limitations established (11.2% [95% CI, 1.9%-57.3%]) and reversal of treatment limitations during or following ICU admission (20.2% [95% CI, 1.8%-76.2%]). The observed variability could not be consistently explained using measurable center-level characteristics.
  
  
  CONCLUSIONS
  Intensive care units vary dramatically in how they manage care for patients admitted with treatment limitations. Among patients who survive, escalations in the aggressiveness of care are more common during the ICU stay than are de-escalations in aggressiveness. This study cannot directly measure whether care received was consistent with patients' preferences but suggests that ICU culture and physicians' practice styles contribute to the aggressiveness of care.
authors.affiliation: Division of Pulmonary, Allergy & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia3Fostering Imp.
authors.forename: Joanna L
authors.initials: JL
authors.lastname: Hart
authors.affiliation: Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia4Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
authors.forename: Michael O
authors.initials: MO
authors.lastname: Harhay
authors.affiliation: Fostering Improvement in End-of-Life Decision Science Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia4Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
authors.forename: Nicole B
authors.initials: NB
authors.lastname: Gabler
authors.affiliation: Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
authors.forename: Sarah J
authors.initials: SJ
authors.lastname: Ratcliffe
authors.affiliation: Department of Medicine, Pulmonary Diseases and Critical Care, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York.
authors.forename: Caroline M
authors.initials: CM
authors.lastname: Quill
authors.affiliation: Division of Pulmonary, Allergy & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia3Fostering Imp.
authors.forename: Scott D
authors.initials: SD
authors.lastname: Halpern
mesh_terms: D024362:Advance Directive Adherence / Q000706:statistics & numerical data*; D016223:Advance Directives / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008020:Life Support Care / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014481:United States
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