End-of-Life Care in ICUs

End-of-life care has been targeted for spending reductions because that care tends to be very intensive and expensive.  One of the most expensive settings for end-of-life care is an intensive care unit.  Both in the United States and in other developed countries there has been an attempt to limit life-prolonging care for patients who are obviously terminal.  An analysis carried by the Journal of the American Medical Association looks at changes in some treatment practices in European ICUs, comparing patients from 1999-2000 with patients from 2015-2016.   (JAMA Article)   The authors examined prevalence of withholding life-prolonging therapies, withdrawing those therapies once started, active shortening of the dying process, failed cardiopulmonary resuscitation attempts and brain death.  About 1785 patients were included for the 2015-16 period and 2807 from the 1999-2000 period.  About 90% of patients in the later cohort had limitations on life-sustaining therapies compared to only 68% in the earlier one.  In 1999-2000 32% of patients died with no such limitations, while only 10% did by 2015-16.  Patients were about 3 years older in the later group and there were more ICU admissions.  There was lower overall ICU mortality.  In 2015-16 the rate of failed CPR was 6% compared to 22% in the earlier period.  Rates of brain death were also less frequent in the later period, 4% compared to 9%.  Life-prolonging therapies were withheld for 50% of patients in 2015-16 compared to 41% in 1999-2000.  These therapies were withdrawn for 39% of patients in the later period versus 25% in the earlier cohort.  But active shortening of the dying process was less common in 2015-16 at 1% of patients compared to 3% of the earlier group.  Among all patients admitted to the ICUs included in the study, hospital mortality was lower in the later time period than the earlier one.  Interestingly, survival after being in an ICU with a life-prolonging therapy limitation or withdrawal was better in the later period than the earlier one.  The changes in use of life-prolonging therapies likely stems from intensive efforts to educate patients and get them to agree to such limitations ahead of time.  Palliative care approaches have been refined and expanded in ICUs.  The increase in survival suggests that notwithstanding reduced use of life-prolonging treatment, overall care is good enough that many patients live through their ICU stay.  I suspect we would see similar trends in the United States, where there also has been a shift to trying to facilitate patients dying at home and avoiding often futile intensive end-of-life care.