End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units

Purpose: To appraise the end-of-life decision-making in several intensive care units (ICUs) and to evaluate the association between the average inclination to limit treatment and overall survival at ICU level. Design: Prospective, multicenter, observational study, lasting 12 months. Setting: Eighty-four Italian, adult ICUs. Patients: Consecutive patients (3,793) who died in ICU or were discharged in terminal condition, in 2005. Measurements: Data collection included patient description, treatment limitation and decisionmakers, involvement of patients and relatives in the decision, and organ donation. A logistic regression model was used to identify predictors of treatment limitation and develop a measure of the inclination to limit treatment for each ICU. This was compared with the standardized mortality ratio, an index of the overall performance of the unit. Results: Treatment limitation preceded 62% of deaths. In 25% of cases, nurses were involved in the decision. Half the limitations were do-notresuscitate orders, with the remaining half almost equally split between withholding and withdrawing treatment. Units less inclined to limit treatments (odds ratio\0.77) showed higher overall standardized mortality ratio (1.08; 95% confidence interval: 1.04–1.12). Limitations: The voluntary nature of participation, with selfselected ICUs from a self-selected independent network. Conclusions: Treatment limitation is common in ICU and still principally a physician’s responsibility. Units with below-average inclination to limit treatments have worse performance in that limitation is not against the patient’s interests. On the contrary, the inclination to limit reatments at the end of life can be taken as an indication of quality in the unit.