Decision-making on withholding or withdrawing life-support in the ICU: A worldwide perspective

Background

Many critically ill patients who die will do so after a decision has been made to withhold/withdraw life-sustaining therapy. Our objective was to document the characteristics of intensive care unit (ICU) patients with a decision to withhold/withdraw life-sustaining treatment, including the types of supportive treatments used, patterns of organ dysfunction, and international differences, including gross national income (GNI).

Methods

In this observational cohort study conducted in 730 ICUs in 84 countries, all adult patients admitted between May 8 and May 18, 2012, except admissions for routine postoperative surveillance, were included.

Results

The analysis included 9,524 patients, with a hospital mortality of 24%. A decision to withhold/withdraw life-sustaining treatment was reported during the ICU stay in 1,259 patients (13%), including 820 (40%) non-survivors and 439 (5%) survivors. Hospital mortality in patients with a decision to withhold/withdraw life-sustaining treatment was 69%. The proportion of deaths in patients with a decision to withhold/withdraw life-sustaining treatment ranged from 10% in South Asia to 67% in Oceania. Decisions to withhold/withdraw life-sustaining treatment were less frequent in low/lower-middle GNI countries than in high GNI countries (6% vs 14%, ptwo organ failures, severe comorbidities, medical and trauma admissions and admission from the emergency room or hospital floor were independent predictors of a decision to withhold/withdraw life-sustaining treatment.

Conclusions

There is considerable worldwide variability in decisions to withhold/withdraw life-sustaining treatments. Interestingly, almost one-third of patients with a decision to withhold/withdraw life-sustaining treatment left the hospital alive.

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