Changes in limitations of life-sustaining treatments over time in a French intensive care unit: A prospective observational study

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Background:Variability exists between ICUs in the limitations of therapy. Moreover practices may evolve over time. This single-center observational study aimed to compare withholding or withdrawing practices between 2012 and 2016.Methods:For each period and patient concerned by limitations, withholding “do-not start”, withholding “do-not-increase” and withdrawal measures were recorded.Results:At a four-year interval, the rate of patients undergoing withholding or withdrawal rose from 10 to 23% and 4 to 7%, respectively. The proportion of patients dying in the ICU with previous limitations increased (53 to 89%), as did patients discharged alive despite withholding instructions (12 to 36%). The overall mortality (28%) was stable over time as the rate of failed resuscitation attempt declined (47 to 11%). In 2016 vs 2012, limitations started earlier following admission: 1 vs 7 days for withholding” do-not-start”, 4 vs 8 for withholding “do-not-increase”, 4 vs 7 for withdrawal. Notwithstanding the outcome and limitations applied, the median length of ICU stay of patients involved dropped from 13 days in 2012 to 8 days in 2016.Conclusion:A timely inclination to forego hopeless treatments resulted in a lower rate of failed resuscitations before death without change in global mortality.HighlightsTreatment limitations are increasingly common and occurred earlier during ICU stay.Patient's wishes regarding end-of-life care should be better addressed by caregivers.Advance care planning reduces both ICU stay and the rate of failed resuscitations.

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