title: Respective impact of no escalation of treatment, withholding and withdrawal of life-sustaining treatment on ICU patients' prognosis: a multicenter study of the Outcomerea Research Group.
abstract: OBJECTIVE
  To assess the prevalence of decisions to forgo life-sustaining treatment (DFLST), the patients characteristics, and to estimate the impact of DFLST stages on mortality.
  
  
  METHODS
  Observational study of a prospective database between 2005 and 2012 from 13 ICUs. DFLST were defined as follows: no escalation of treatment (stage 1), not to start or escalate treatment even if such treatment is considered in the future; withholding (stage 2), not to start or escalate necessary treatment; withdrawal (stage 3), to stop necessary treatment. The impact of daily DFLST stage on day-30 hospital mortality was tested with a discrete-time Cox's model and adjusted for admission severity and daily SOFA score.
  
  
  RESULTS
  Of 10,080 patients, 1290 (13%) made DFLST. The highest DFLST stage during the ICU stay was no escalation of treatment in 339 (26%) patients, withholding in 502 (39%) patients, and withdrawal in 449 (35%) patients. Older patients, patients with at least one chronic disease, and patients with greater ICU severity were significantly more numerous in the DFLST group. Day-30 mortality was 13% for non-DFLST patients, 35% for no escalation of treatment, 75% for withholding, 93% for withdrawal. After adjustment, an increase in day-30 mortality was associated with withholding and withdrawal (hazard ratio 95% CI 5.93 [4.95-7.12] and 20.05 [15.58-25.79], P < 0.0001), but not with no escalation of treatment (HR 1.14 [0.91-1.44], P = 0.25).
  
  
  CONCLUSIONS
  DFLST were made in 13% of ICU patients. Withholding, withdrawal, older age, more comorbidities, and higher severity of illness were associated with higher mortality. No escalation of treatment was not associated with increased mortality.
authors.affiliation: Medical Intensive Care Unit, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand Cedex 1, France. alautrette@chu-clermontferrand.fr.|LMGE (Laboratoire Micro-organismes: Génome et Environnement), UMR CNRS 6023, Clermont-University, Clermont-Ferrand, France. alautrette@chu-clermontferrand.fr.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Lautrette
authors.affiliation: Critical Care Medicine Unit, Saint-Joseph Hospital, Paris, France.
authors.forename: Maïté
authors.initials: M
authors.lastname: Garrouste-Orgeas
authors.affiliation: Medical Intensive Care Unit, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand Cedex 1, France.
authors.forename: Pierre-Marie
authors.initials: PM
authors.lastname: Bertrand
authors.affiliation: Critical Care Medicine Unit, Gonesse Hospital, Gonesse, France.
authors.forename: Dany
authors.initials: D
authors.lastname: Goldgran-Toledano
authors.affiliation: Critical Care Medicine Unit, Dourdan Hospital, Dourdan, France.
authors.forename: Samir
authors.initials: S
authors.lastname: Jamali
authors.affiliation: Critical Care Medicine Unit, Versailles Hospital, Le Chesnay, France.
authors.forename: Virginie
authors.initials: V
authors.lastname: Laurent
authors.affiliation: Medical Intensive Care Unit, Edouard Herriot Teaching Hospital, University of Lyon, Lyon, France.
authors.forename: Laurent
authors.initials: L
authors.lastname: Argaud
authors.affiliation: Medical Intensive Care Unit, Albert Michallon Teaching Hospital, University Hospital of Grenoble, Grenoble, France.
authors.forename: Carole
authors.initials: C
authors.lastname: Schwebel
authors.affiliation: Medical Intensive Care Unit, Bichat-Claude Bernard Teaching Hospital, AP-HP, Paris, France.
authors.forename: Bruno
authors.initials: B
authors.lastname: Mourvillier
authors.affiliation: Medical Intensive Care Unit, Nord Teaching Hospital, University of Saint Etienne, Saint Etienne, France.
authors.forename: Michaël
authors.initials: M
authors.lastname: Darmon
authors.affiliation: U823 "Outcome of cancers and critical illness", Albert Bonniot Institute, 38076, La Tronche, France.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Ruckly
authors.affiliation: Surgical Intensive Care Unit, Antoine Beclere University Hospital, Clamart, France.
authors.forename: Anne-Sylvie
authors.initials: AS
authors.lastname: Dumenil
authors.affiliation: Medical Intensive Care Unit, Saint Louis Teaching Hospital, AP-HP, Paris, France.
authors.forename: Virginie
authors.initials: V
authors.lastname: Lemiale
authors.affiliation: Medical Intensive Care Unit, Gabriel Montpied Teaching Hospital, University Hospital of Clermont-Ferrand, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand Cedex 1, France.|LMGE (Laboratoire Micro-organismes: Génome et Environnement), UMR CNRS 6023, Clermont-University, Clermont-Ferrand, France.
authors.forename: Bertrand
authors.initials: B
authors.lastname: Souweine
authors.affiliation: Medical Intensive Care Unit, Bichat-Claude Bernard Teaching Hospital, AP-HP, Paris, France.|U823 "Outcome of cancers and critical illness", Albert Bonniot Institute, 38076, La Tronche, France.
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Timsit
mesh_terms: D000328:Adult; D000368:Aged; D003657:Decision Making; D005260:Female; D005602:France; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008020:Life Support Care / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009026:Mortality; D064887:Observational Studies as Topic; D011379:Prognosis; D011446:Prospective Studies; D016414:Resuscitation Orders; D028761:Withholding Treatment / Q000706:statistics & numerical data*
keywords: Critical care; Decision-making; Do-not-resuscitate; End-of-life; Prognosis