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Treatment limitations at admission to intensive care units in Australia and New Zealand

Prevalence, outcomes, and resource use*

Godfrey, George BM; Pilcher, David MRCP, FRACP, FCICM; Hilton, Andrew FANZCA, FCICM; Bailey, Michael PhD, MSc(statistics), BSc(hons); Hodgson, Carol L. PhD, FACP, BAppSc, PGDip(Cardio), M(Research); Bellomo, Rinaldo MBBS, MD, FRACP, FCICM

doi: 10.1097/CCM.0b013e31824ea045
Clinical Investigations

Background: Previous studies have addressed patients in whom treatment is withheld or withdrawn after a period of intensive care unit management. However, no studies have investigated the epidemiology of patients with treatment limitations in place at the time of intensive care unit admission.

Objective: To report the epidemiology and outcome of patients with treatment limitations at intensive care unit admission and to identify characteristics associated with survival and discharge to home.

Design: Retrospective database study using data from the Australian and New Zealand Intensive Care Society Adult Patient Database.

Setting: Australian and New Zealand intensive care units.

Patients: One hundred eighty-seven thousand four hundred and one intensive care patients collected over a 3-yr period, 5,989 (3.2%) of whom had treatment limitations at admission to the intensive care unit.

Interventions: Retrospective database study with no interventions. Data collected included patient characteristics, length of stay, mortality, and discharge destination. Mean intensive care unit bed days were used as a surrogate for resource consumption.

Measurements and Main Results: Between January 1, 2007, and December 31, 2009, 5,989 (3.2%) patients were reported to the Australia and New Zealand Intensive Care Society Adult Patient Database who had treatment limitation orders at admission to intensive care unit. Mortality was 53% (95% confidence interval 51.7%–54.3%) compared with 9% (95% confidence interval 8.9%–9.1%) in patients admitted for full active management (p ≤ .001). Overall, 30% of patients with treatment limitations were discharged directly to their homes. Intensive care unit bed day usage was similar between the two groups. Within the treatment limitation group, younger patients, those with less comorbid diseases, less acute physiological disturbance, and those admitted following elective surgery, were more likely to survive and be discharged home. Admission diagnosis was an important determinant of outcome with intracranial or subarachnoid hemorrhage predicting a extremely high mortality.

Conclusions: Patients with treatment limitations on intensive care unit admission comprise approximately 2,000 patients per year in Australia and New Zealand. Despite such limitations, almost half of these patients survive their hospital admission and a third return directly to their home.

From the Department of Intensive Care (GG, DP, AH, CLH), The Alfred Hospital, Melbourne, Victoria, Australia; Australian and New Zealand Intensive Care Society Centre for Outcomes and Resource Evaluation (DP, MB), Carlton, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre (DP, MB, CLH, RB), Department of Epidemiology & Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia; and Department of Intensive Care (RB), The Austin Hospital, Heidelberg, Melbourne, Victoria, Australia.

*See also p. 2239.

Dr. Hodgson is emplyed by ANZICS-RC as a senior research fellow. The remaining authors have not disclosed any potential conflicts of interest.

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© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins