Six to 25 percent of patients discharged alive from the intensive care unit (ICU) die before hospital discharge. Although this post-ICU mortality may indicate premature discharge from a full ICU or suboptimal management in the ICU or ward, another factor may be discharge from the ICU as part of a decision to limit treatment of hopelessly ill patients. We investigated determinants of post-ICU mortality, with special attention to this factor.
Prospective, multicenter, database study.
Seven ICUs in or near Paris, France.
A total of 1,385 patients who were discharged alive from an ICU after a stay of ≥48 hrs; 150 (10.8%) died before hospital discharge. Decisions to withhold or withdraw life-sustaining treatments were implemented in the ICUs in 80 patients, including 47 (58.7%) who died before hospital discharge.
In the univariate analysis, post-ICU mortality was associated with advanced age, poor chronic health status, severe comorbidities, severity and organ failure scores (Simplified Acute Physiology Score II, sepsis-related organ failure assessment, and Logistic Organ Dysfunction at admission and at ICU discharge), decisions to withhold or withdraw life-sustaining treatments, and Omega score (reflecting ICU resource utilization and length of ICU stay). Multivariate stepwise logistic regression identified five independent determinants of post-ICU mortality: McCabe class 1 (odds ratio, 0.388 [95% confidence interval, 0.26–0.58]), transfer from a ward (odds ratio, 1.89 [95% confidence interval, 1.27–2.80]), Simplified Acute Physiology Score II score at admission >36 (odds ratio, 1.57 [95% confidence interval, 1.6–2.33]), decisions to withhold or withdraw life-sustaining treatments (odds ratio, 9.64 [95% confidence interval, 5.75–16.6]), and worse sepsis-related organ failure assessment score at discharge (odds ratio, 1.11 [95% confidence interval, 1.03–1.18] per point).
More than 10% of ICU survivors died before hospital discharge. Determinants of post-ICU mortality included variables reflecting patient status before and during the ICU stay. However, the most powerful predictor of post-ICU mortality was the decision to withhold or withdraw life-sustaining treatments in the ICU, suggesting that the decision has been made not to use the unique services of the ICU for these patients.
From the Medical ICU, Hôpital Saint Louis, Paris; Medical and Surgical ICU, Saint Denis; Medical ICU, Hôpital Louis Mourier, Colombes; Polyvalent and Vascular Surgical ICU, Hôpital Saint Joseph, Paris; Surgical ICU, Hôpital Antoine Béclère, Clamart; Surgical ICU, Hôpital Bicêtre, Le Kremlin-Bicêtre; Biostatistics Department, Hôpital Robert Debré, Paris; Medical and Surgical ICU, Hôpital Avicenne, Bobigny; and Medical ICU, Hôpital Bichat Claude Bernard, Paris, France.
Outcomerea is supported, in part, by nonexclusive educational grants from Aventis Pharma, France, Wyeth-Lederle, and Centre National de Recherche Scientifique.
Presented at the congress of the European Society of Intensive Care Medicine, Geneva, Switzerland, September 30 to October 3, 2001.