Variability Among US Intensive Care Units in Managing the Care of Patients Admitted With Preexisting Limits on Life-Sustaining Therapies

In JAMA Internal Medicine, Scott Halpern and colleagues investigate variance in end-of-life care in intensive care units (ICUs) by looking at a group of patients with presumably similar care preferences. The authors compared the care received at 141 ICUs by patients with pre-existing limits on life-sustaining treatments, and the proportions of such patients who received aggressive care. The care outcomes measured were: provision of cardiopulmonary resuscitation, new forms of life support, and the addition or removal of treatment limitations. Of the ICU admissions evaluated, 4.8% of patients had established treatment limitations. Patients admitted with treatment limitations were more likely to be older with more functional limitations and comorbidities. The authors find that among patients who survive, escalations in the aggressiveness of care are more common during the ICU stay than are de-escalations in aggressiveness. Of those who survive, 17.8% received reversals of previous care limitations, while 11.7% received new limitations. There is considerable variability between different ICUs, though none of the variation is easily explainable using measurable center-level characteristics. The study cannot directly measure whether care received was consistent with patients’ preferences, but findings suggest that ICU culture and physicians’ practice styles contribute to the aggressiveness of care.