Timing of Limitations in Life Support in Acute Lung Injury Patients

Abstract

Objective Substantial variability exists in the timing of limitations in life support for critically ill patients. Our objective was to investigate how the timing of limitations in life support varies with changes in organ failure status and time since acute lung injury (ALI) onset. Design, Setting, and Patients This evaluation was performed as part of a prospective cohort study evaluating 490 consecutive ALI patients recruited from 11 intensive care units (ICUs) at three teaching hospitals in Baltimore, MD. Interventions None. Measurements The primary exposure was proportion of days without improvement in Sequential Organ Failure Assessment (SOFA) score, evaluated as a daily time-varying exposure. The outcome of interest was a documented limitation in life support defined as any of the following: (1) No CPR, (2) Do not re-intubate, (3) No vasopressors, (4) No hemodialysis, (5) Do not escalate care or (6) Other limitation (e.g., “comfort care only”). Main Results For medical ICU (MICU) patients without improvement in daily SOFA score, the rate of limitation in life support tripled in the first three days after ALI onset, increased again after Day 5, and peaked at Day 19. Compared to MICU patients, surgical ICU (SICU) patients had a rate of limitations that was significantly lower during the first five days after ALI onset. In all patients, more days without improvement in SOFA scores was associated with limitations in life support, independent of the absolute magnitude of the SOFA score. Conclusions Persistent organ failure is associated with an increase in the rate of limitations in life support independent of the absolute magnitude of SOFA score, and this association strengthens during the first weeks of treatment. During the first five days after ALI onset limitations were significantly more common in MICUs than SICUs.

Clinical and Economic Implications of Timing of Limitations in Life Support*

“…Interestingly, in this study, only 23% of SICU patients were admitted from the operating room (8). This suggests that the early lack of limitation of life support interventions in the SICU is not only attributed to the "informal agreement" regarding postoperative use of Ufe support.…”

“…When advanced care planning is routinely introduced to patients and their families in an outpatient setting, reopening a familiar discussion in the setting of a critical illness is not only easier and more effective for patients and families but may also reduce the time needed for clinicians to conduct these conferences. These early family conferences also offer the opportunity to discuss the concept of a "time-limited trial" of critical care (12) and may facilitate early decision making that is influenced by the trajectory of illness, such as the lack of improvement shown to predict limitations of life support in this study (8). Importantly, earlier family conferences can lead to limitations in life support being implemented earlier without increasing ICU mortality (13).…”

“…Second, early on, SICU patients were less likely to have limitations in life support. Lastly, patients who did not demonstrate consistent improvement in organ function had higher limitation rates than those who displayed improvement, even after adjusting for the magnitude ofthe daily SOFA score (8). This study uses sophisticated, time-varying, multivariate analyses to better describe the complex and dynamic patterns of decisions to hmit life support.…”

Limitação do suporte de vida na terapia intensiva: percepção médica

“…However, despite the fact that LSL is a growing practice in the world 3,4 , it is still surrounded by conflicts, because even with legal protection there are persistent insecurities and difficulties regarding the decision-making process for its adoption [5][6][7] .…”

The authors reply

“…Sprung (1) for his comments regarding our study evaluating the association between changes in organ failure status and limitations in the use of life support (2). We agree that advance directives and neurological disorders are important factors associated with the use of life support (3).…”