The association between the decision to withdraw life-sustaining therapy and patient mortality in U.K. ICUs

OBJECTIVES: Differences in decisions to limit life-sustaining therapy are often supported by perceptions that patients receive unnecessary and expensive treatment which provide negligible survival benefit. However, the assumption behind those beliefs - that is, that life-sustaining therapy provides no significant marginal survival benefit - remains unproven. Our objective was to quantify the effects of variations in decisions to withdraw or withhold life-sustaining treatment on 180-day mortality in critically ill patients. DESIGN: Retrospective observational cohort study of a national clinical database. SETTING: Adult ICUs participating in the Intensive Care National Audit and Research Center Case Mix Program in the United Kingdom. PATIENTS: Adult patients admitted to general ICUs between April 1, 2009, and March 31, 2016. MEASUREMENTS AND MAIN RESULTS: During the study period, 795,721 patients were admitted to 247 ICUs across the United Kingdom. A decision to withdraw or withhold life-sustaining treatment was made for 92,327 patients (11.6%). A multilevel model approach was used to estimate ICU-level practice variation. The ICU-level practice variation was then used as an instrument to measure the effects of decision to withdraw or withhold life-sustaining treatment on 180-day mortality. The marginal population was estimated to be 5.9% of the total cohort. A decision to withdraw or withhold life-sustaining treatment was associated with a marginal increase in 180-day mortality of 25.6% (95% CI, 23.2-27.9%). CONCLUSIONS: Decision to withdraw or withhold life-sustaining treatment in critically ill adults in the United Kingdom was associated with increased 180-day mortality in the marginal patients. The increased mortality from a decision to withdraw or withhold life-sustaining treatment in the marginal patient may be informative when establishing patients' preferences and evaluating the cost-effectiveness of intensive treatments.