Resuscitation. 2023 Sep 1:109956. doi: 10.1016/j.resuscitation.2023.109956. Online ahead of print.
ABSTRACT
AIM: Frequency and timing of Withdrawal of Life-Sustaining Treatment (WLST) after Out-of-Hospital Cardiac Arrest (OHCA) vary across Intensive Care Units (ICUs) in the United Kingdom (UK) and may be a marker of lower healthcare quality if instituted too frequently or too early. We aimed to describe WLST practice, quantify its variability across UK ICUs, and assess the effect of institutional deviation from average practice on patients’ risk-adjusted hospital mortality.
METHODS: We conducted a retrospective multi-centre cohort study including all adult patients admitted after OHCA to UK ICUs between 2010-2017. We identified patient and ICU characteristics associated with early (within 72h) and late (>72h) WLST and quantified the between-ICU variation. We used the ICU-level observed-to-expected (O/E) ratios of early and late-WLST frequency as separate metrics of institutional deviation from average practice and calculated their association with patients’ hospital mortality.
RESULTS: We included 28438 patients across 204 ICUs. 10775 (37.9%) had WLST and 6397 (59.4%) of them had early-WLST. Both WLST types were strongly associated with patient-level demographics and pre-existing conditions but weakly with ICU-level characteristics. After adjustment, we found unexplained between-ICU variation for both early-WLST (Median Odds Ratio 1.59, 95%CrI 1.49-1.71) and late-WLST (MOR 1.39, 95%CrI 1.31-1.50). Importantly, patients’ hospital mortality was higher in ICUs with higher O/E ratio of early-WLST (OR 1.29, 95%CI 1.21-1.38, p<0.001) or late-WLST (OR 1.39, 95%CI 1.31-1.48, p<0.001).
CONCLUSIONS: Significant variability exists between UK ICUs in WLST frequency and timing. This matters because unexplained higher-than-expected WLST frequency is associated with higher hospital mortality independently of timing, potentially signalling prognostic pessimism and lower healthcare quality.
PMID:37661013 | DOI:10.1016/j.resuscitation.2023.109956
