title: End-of-life decisions in surgical intensive care medicine - the relevance of blood transfusions.
abstract: BACKGROUND
  End-of-life decisions (EOLDs) are common in the intensive care unit (ICU). EOLDs underlie a dynamic process and limitation of ICU-therapies is often done sequentially. Questionnaire-based and observational studies on medical ICUs and in palliative care reveal blood transfusions as the first therapy physicians withhold as an EOLD.
  
  
  METHODS
  To test whether this practice also applies to surgical ICU-patients, in an observational study, all deceased patients (n = 303) admitted to an academic surgical ICU in a three-year period were analyzed for the process of limiting ICU-therapies.
  
  
  RESULTS
  Restriction of further surgery (85.4%) and limiting doses of vasopressors (75.8%) were the most frequent forms of limitations in surgical ICU therapies. Surgical patients, who had blood transfusions withheld (44.6%), had more ICU-therapies withheld or withdrawn simultaneously than patients who had transfusions maintained (5 ± 2 vs. 2 ± 1, p < 0.001). Secondary EOLDs and subsequent limitations occurred less frequently in patients who had transfusions withheld with their first EOLD (17.1% vs. 35.6%, p < 0.05).
  
  
  CONCLUSIONS
  Limitation orders for blood transfusions are not a prioritized decision in EOLDs of surgical ICU patients. Withholding blood transfusions correlates with discontinuation of further significant life-support therapies. This suggests that EOLDs to withhold blood transfusions are part of the most advanced limitations of therapy on the surgical ICU.
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Germany. Electronic address: jan.graw@charite.de.
authors.forename: Jan A
authors.initials: JA
authors.lastname: Graw
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Germany.
authors.forename: Claudia D
authors.initials: CD
authors.lastname: Spies
authors.affiliation: Charité - Universitätsmedizin Berlin and SOSTANA GmbH, Berlin, Germany.
authors.forename: Klaus-D
authors.initials: KD
authors.lastname: Wernecke
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, HELIOS Klinikum Hildesheim, Germany.
authors.forename: Jan-P
authors.initials: JP
authors.lastname: Braun
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion; D003657:Decision Making; D006801:Humans; D007362:Intensive Care Units; D008020:Life Support Care; D008875:Middle Aged; D011795:Surveys and Questionnaires; D013727:Terminal Care
keywords: Blood transfusion; End-of-life decision; Intensive care medicine; Limitation order; Surgical intensive care unit