title: Effect of ICU strain on timing of limitations in life-sustaining therapy and on death.
abstract: OBJECTIVE
  The effect of capacity strain in an ICU on the timing of end-of-life decision-making is unknown. We sought to determine how changes in strain impact timing of new do-not-resuscitate (DNR) orders and of death.
  
  
  METHODS
  Retrospective cohort study of 9891 patients dying in the hospital following an ICU stay ≥72 h in Project IMPACT, 2001-2008. We examined the effect of ICU capacity strain (measured by standardized census, proportion of new admissions, and average patient acuity) on time to initiation of DNR orders and time to death for all ICU decedents using fixed-effects linear regression.
  
  
  RESULTS
  Increases in strain were associated with shorter time to DNR for patients with limitations in therapy (predicted time to DNR 6.11 days for highest versus 7.70 days for lowest quintile of acuity, p = 0.02; 6.50 days for highest versus 7.77 days for lowest quintile of admissions, p < 0.001), and shorter time to death (predicted time to death 7.64 days for highest versus 9.05 days for lowest quintile of admissions, p < 0.001; 8.28 days for highest versus 9.06 days for lowest quintile of census, only in closed ICUs, p = 0.006). Time to DNR order significantly mediated relationships between acuity and admissions and time to death, explaining the entire effect of acuity, and 65 % of the effect of admissions. There was no association between strain and time to death for decedents without a limitation in therapy.
  
  
  CONCLUSIONS
  Strains in ICU capacity are associated with end-of-life decision-making, with shorter times to placement of DNR orders and death for patients admitted during high-strain days.
authors: Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street PH5, Room 527D, New York, NY, 10032, USA. mh2633@cumc.columbia.edu.
authors: May
authors: M
authors: Hua
authors: Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.|Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA.|Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.|Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, USA.|Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
authors: Scott D
authors: SD
authors: Halpern
authors: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.|Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, USA.
authors: Nicole B
authors: NB
authors: Gabler
authors: Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Canada.|Department of Anesthesia and Interdisciplinary Department of Critical Care Medicine, University of Toronto, Toronto, Canada.|Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA.
authors: Hannah
authors: H
authors: Wunsch
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016638:Critical Illness / Q000401:mortality*; D016208:Databases, Factual; D003657:Decision Making; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007902:Length of Stay; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D016414:Resuscitation Orders; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013727:Terminal Care; D013997:Time Factors; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
chemical_list: D014662:Vasoconstrictor Agents
keywords: Critical care; Decision-making; End-of-life care; Palliative care