Patient Directives May Change in Intensive Care Unit

By Sondra Forsyth

Although more and more people have set clear limits on how much life-sustaining therapy they want, intensive-care units across the U.S. vary widely in how they manage the care of those patients.

The pre-existing limits include authorizing do-not-resuscitate orders, and prohibiting treatments such as feeding tubes or dialysis.

The research, from investigators at the Perelman School of Medicine at the University of Pennsylvania, was published in JAMA Internal Medicine.

“We’ve long known that end-of-life and critical care varies across nations, regions and centers, whether from changes in local policies, practice culture or resource constraints,” said the study’s lead author Joanna L. Hart, MD, MSHP, a pulmonary and critical care physician and post-doctoral research fellow at Penn. “But, we hypothesized that by looking at this specific patient population, we could attribute this variability as an appropriate response to patient preferences in care, and undue or unsupported variability. No previous studies we’re aware of have analyzed variations in care for patients who, upon admission, have similar care requests.”

In their study, the researchers looked at statistics from patients from 141 intensive care units in 105 hospitals, for a total of 277,693 patients from April 2001 through December 2008, according to a news release from the university.

They found that that 4.8 percent of ICU admissions were patients with preexisting limits on care. The limits for most patients included DNR orders, which included preferences prohibiting chest compressions, intubation and use of defibrillation to restart their hearts.

Other patients had documented restrictions on acceptable therapies, ranging from dialysis to nutritional support such as feeding tubes (21 percent), and four percent expressed a preference for comfort measures only, the news release said.

However, the investigators found that these patients’ preferences were often changed during their stay. Overall, 41 percent of patients who entered with treatment limitations got one or more forms of life support, and 18 percent had a reversal of previous treatment limitations.

The researchers discovered that when the ICU was managed by a critical-care physician, the odds were greater that the limitations would change. Suburban hospitals also had greater odds that patients would have new treatment limitations established during their stay.

“The variability here is astounding and no matter how hard we tried, we could not make it go away by accounting for any differences among the patients admitted to different ICUs,” says the study’s senior author, Scott Halpern, MD, PhD, MBE, assistant professor of Medicine, Epidemiology, and Medical Ethics and Health Policy. “Surprisingly, for patients who had already outlined ‘I don’t want this or that procedure or treatment at end of life,’ escalations of treatment intensity were nonetheless more common than de-escalations,” said Halpern.

“This tendency toward aggressiveness varies widely depending only on which ICU a patient happens to be admitted to. There seems to be great potential for better aligning the outcomes of critical care with the outcomes people desire through a better understanding of how treatment decisions are made for patients who can and cannot communicate their preferences. We suggest that having clear, effective advance directives along with accompanying conversations with potential surrogate decision makers (usually family) is the best way to prevent unwanted care during an ICU stay.”