Patients with limitation or withdrawal of life supporting care admitted in a medico-surgical intermediate care unit: Prevalence, description and outcome over a six-month period

Autoři: Perrine Molmy aff001;  Nicolas Vangrunderbeeck aff001;  Olivier Nigeon aff001;  Malcolm Lemyze aff002;  Didier Thevenin aff002;  Jihad Mallat aff001
Působiště autorů: Intermediate Care Unit, Centre Hospitalier de Lens, Lens, France aff001;  Intensive Care Unit, Centre Hospitalier de Lens, Lens, France aff002;  Respiratory & Infectious Diseases Unit, Centre Hospitalier de Lens, Lens, France aff003;  Department of Critical Care Medicine, Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE aff004
Vyšlo v časopise: PLoS ONE 14(11)
Kategorie: Research Article
doi: 10.1371/journal.pone.0225303



There have been few studies on the limitation of Life Supporting Care (LSC) and Withdrawal of LSC in Intermediate Care Units (IMCUs). We report the prevalence of LSC limited patients in a medico-surgical IMCU over a six-month period, examining the description, outcomes, and patterns of LSC Limitations and Withdrawal of LSC.


Single center, retrospective observational study in an IMCU of a 500-bed general hospital.


Our study of 404 patients, reported 79 (19.5%, 95%CI: [16.0–23.7]%) being admitted with LSC limitations in the IMCU. This group of LSC limited patients presented with higher chronic and acute severity scores. The most common admission diagnosis of LSC limited patients was acute respiratory failure (51%). Non-invasive ventilation (NIV) was frequently used within this population (39%). Hospital mortality for LSC limited patients was high (53%) and associated with age (OR = 1.07, 95%CI: [1.01–1.13)]), SOFA score (OR 1.29, 95%CI: [1.01–1.64]), and hypoxemic respiratory failure (OR 7.2, 95%CI: [1.27–40.9]). Withdrawal of LSC occurred in 19.5% of cases, often accompanied with terminal sedation with or without NIV removal (43.8%).


Patients with limitation of LSC are frequently admitted into IMCU. Hospital mortality rate was high and associated with age, acute organ failures, and hypoxemic respiratory failure. Life support withdrawal includes palliative sedation with or without NIV discontinuation.

Klíčová slova:

Critical care and emergency medicine – Death rates – Diagnostic medicine – Hospitals – Intensive care units – Physicians – Respiratory failure – Surgical and invasive medical procedures


1. Rosenthal GE, Sirio CA, Shepardson LB, Harper DL, Rotondi AJ, Cooper GS. Use of intensive care units for patients with low severity of illness. Arch Intern Med 1998; 158 (10):1144–51. doi: 10.1001/archinte.158.10.1144 9605788

2. Prin M, Wunsch H. The role of stepdown units in hospital care. Am J Respir Crit Care Med 2014; 190(11):1210–6. doi: 10.1164/rccm.201406-1117PP 25163008

3. Vincent JL, Rubenfeld GD. Does intermediate care improve patient outcomes or reduce costs? Crit Care 2015; 19: 89. doi: 10.1186/s13054-015-0813-0 25774925

4. Prin M, Harrison D, Rowan K, Wunsch H. Epidemiology of Admissions to 11 stand-alone high-dependency care units in the UK. Intensive Care Med 2015; 41(11): 1903–10. doi: 10.1007/s00134-015-4011-y 26359162

5. Nava S, Sturani C, Hartl S, Magni G, Ciontu M, Corrado A, et al. End-of-life decision making in respiratory intermediate care units: a European survey. Eur Respir J 2007; 30 (1): 156–64. doi: 10.1183/09031936.00128306 17601972

6. Alegre F, Landecho MF, Huerta A, Fernández-Ros N, Martínez-Urbistondo D, García N, et al. Design and Performance of a New Severity Score for Intermediate Care. PLoS One 2015;10(6): e0130989. doi: 10.1371/journal.pone.0130989 26121578

7. Hager DN, Tanykonda V, Noorain Z, Sahetya SK, Simpson CE, Lucena JF, et al. Hospital mortality prediction for intermediate care patients: Assessing the generalizability of the Intermediate Care Unit Severity Score (IMCUSS). J Crit Care 2018; 46:94–98. doi: 10.1016/j.jcrc.2018.05.009 29804039

8. Lautrette A, Garrouste-Orgeat M, Bertrand PM, Goldgran-Toledano D, Jamali S, Laurent V, et al. Outcomerea Study Group. Respective impact of no escalation of treatment, withholding and withdrawal of life-sustaining treatment on ICU patients’ prognosis: a multicenter study of the Outcomerea Research Group. Intensive Care Med 2015; 41(10): 1763–72. doi: 10.1007/s00134-015-3944-5 26149302

9. Société de réanimation de langue française. Limitation et arrêt des traitements en réanimation adulte. Actualisation des recommandations de la société de réanimation de langue française. Réanimation 2010; 19:679–98.

10. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40(5):373–83. doi: 10.1016/0021-9681(87)90171-8 3558716

11. Christensen S, Johansen MB, Christiansen CF, Jensen R, Lemeshow S. Comparison of Charlson comorbidity index with SAPS and APACHE scores for prediction of mortality following intensive care. Clinical Epidemiology 2011; 3: 203–11. doi: 10.2147/CLEP.S20247 21750629

12. Knaus W, Zimmerman J, Wagner D, Draper EA, Lawrence DE. APACHE Acute Physiology and Chronic Health Evaluation: Physiologically Based Classification System. Crit Care Med 1981; 9(8): 591–97. doi: 10.1097/00003246-198108000-00008 7261642

13. Montuclard L, Garrouste-Orgeas M, Timsit JF, Misset B, De Jonghe B, Carlet J. Outcome, functional autonomy, and quality of life of elderly patients with a long-term intensive care unit stay. Crit Care Med 2000; 28(10):3389–95. doi: 10.1097/00003246-200010000-00002 11057791

14. Hosmer DW, Lemeshow S. Model-Building Strategies and Methods for Logistic Regression. In: Applied Logistic Regression. Second Edition; pp. 91–142.

15. Wunsch H, Harrison DA, Jones A, Rowan K. The impact of the organization of high-dependency care on acute hospital mortality and patient flow for critically ill patients. Am J Respir Crit Care Med 2015; 191(2):186–93. doi: 10.1164/rccm.201408-1525OC 25494358

16. Sjoding MW, Valley TS, Prescott HC, et al. Rising billing for Intermediate Care among hospitalized Medicare beneficiaries between 1996 and 2010. Am J Respir Crit Care Med 2016; 193(2):163–70. doi: 10.1164/rccm.201506-1252OC 26372779

17. Rubio O, Sanchez JM, Fernandez R. Life-sustaining treatment limitation criteria upon admission to the intensive care unit: Results of Spanish national multicenter. Med intensive 2013; 37(5): 333–338.

18. Kahn JM. The evolving role of dedicated weaning facilities in critical care. Intensive Care med 2010; 36(1): 8–10. doi: 10.1007/s00134-009-1672-4 19784621

19. Lapichino G, Corbella D, Minelli C, Mills GH, Artigas A, Edbooke DL, et al. Reasons for refusal of admission to intensive care an impact on mortality. Intensive Care Med 2010; 36(10): 1772–9. doi: 10.1007/s00134-010-1933-2 20533023

20. Quill C, Ratcliffe S, Harhay M, Sporchia A, Mazza M, Pruneri G, et al. Variation in decisions to forgo life-sustaining therapies en US ICUs. Chest 2014; 146 (3):573–82. doi: 10.1378/chest.13-2529 24522751

21. Robert R, Coudroy R, Ragot S, Lesieur O, Runge I, Souday V, et al. Influence of ICU-bed availability on ICU admission decisions. Ann Intensive Care 2015; 5(1):55.

22. Sprung CL, Artigas A, Kesecioglu J, et al. (2012) The Eldicus prospective, observational study of triage decision making in European intensive care units. Part II: Intensive care benefit for the elderly. Crit Care Med 40: 132–138. doi: 10.1097/CCM.0b013e318232d6b0 22001580

23. Martinez-Urbistondo D, Alegre F, Carmona-Torre F, Huerta A, Fernandez-Ros N, Landecho MF, et al. Mortality Prediction in Patients Undergoing Non-Invasive Ventilation in Intermediate Care. PLoS One 2015; 5; 10 (10): e0139702. doi: 10.1371/journal.pone.0139702 26436420

24. Nava S, Hill N. Noninvasive ventilation in acute respiratory failure. Lancet 2009; 374(9685):250–9. doi: 10.1016/S0140-6736(09)60496-7 19616722

25. Azoulay E, Kouatchet A, Jaber S, Lambert J, Meziani F, Schmidt M, et al. Noninvasive mechanical ventilation in patients having declined tracheal intubation. Intensive Care Med 2013; 39(2):292–301. doi: 10.1007/s00134-012-2746-2 23184037

26. Demoule A, Chevret S, Carlucci A, Kouatchet A, Jaber S, Meziani F, et al. Changing use of noninvasive ventilation in critically ill patients: trends over 15 years in francophone countries. Intensive Care Med 2016; 42(1):82–92. doi: 10.1007/s00134-015-4087-4 26464393

27. Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive pressure ventilation reverses acute respiratory failure in select « do not intubate » patients. Crit Care Med 2005; 33(9) 1976–1982. doi: 10.1097/01.ccm.0000178176.51024.82 16148468

28. Lemyze M, Mallat J, Gasan G, Van Grunderbeeck N, Tronchon L, Thevenin D. NIV should be delivered in do-not-intubate patients, but how? Intensive Care Med 2013; 39(5):983.

29. Azoulay E, Demoule A, Jaber S, Kouatchet A, Meert AP, Papazian L, et al. Palliative noninvasive ventilation in patients with acute respiratory failure. Intensive Care Med 2011; 37(8): 1250–1257. doi: 10.1007/s00134-011-2263-8 21656292

30. Hillman K, Cardona-Morrell M. The ten barriers to appropriate management of patients at the end of their life. Intensive Care Med 2015; 41(9): 1700–2. doi: 10.1007/s00134-015-3712-6 25749572

31. Ferrante LE, Pisani MA, Murphy TE, Gahbauer EA, Leo-Summers LS, Gill TM. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015; 175(4): 523–9. doi: 10.1001/jamainternmed.2014.7889 25665067

32. Niederman MS, Berger JT. The delivery of futile care is harmful to other patients. Crit Care Med 2010; 38(10):518–22.

33. Heyland D, Cook D, Bagshaw SM, Garland A, Stelfox HT, Mehta S, et al. The Very Elderly Admitted to ICU: A Quality Finish? Crit Care Med 2015; 43(7):1352–60. doi: 10.1097/CCM.0000000000001024 25901550

34. Binney ZO, Quest TE, Feingold PL, Buchman T, Majesko AA. Feasibility and economic impact of dedicated hospice inpatient units for terminally Ill ICU patients. Crit Care Med 2014; 42(5): 1074–80. doi: 10.1097/CCM.0000000000000120 24351372

35. Angus DC, Barnato AE, Linde-Zwirbe WT, Weissfeld LA, Watson RS, Rickert T, et al. Use of Intensive Care at the end of life in the United States: an epidemiologic study. Crit Care Med 2004; 32(3): 638–43. doi: 10.1097/01.ccm.0000114816.62331.08 15090940

36. Capuzzo M, Volta C, Tassinati T, Moreno R, Valentin A, Guidet B, et al. Hospital mortality of adults admitted to Intensive Care Units in hospitals with and without Intermediate Care Units: a multicentre European cohort study. Crit Care 2014; 18(5): 551. doi: 10.1186/s13054-014-0551-8 25664865

37. Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, et al. End of life practices in European Intensive Care Units, The Ethicus Study. JAMA 2003; 290(6): 790–7. doi: 10.1001/jama.290.6.790 12915432

38. Downar J, You J, Bagshaw S, Golan E, Lamontagne F, Burns K, et al. Non beneficial treatment Canada definitions, causes, and potential solutions from the perspective of healthcare practitioners. Crit Care Med 2015; 43(2): 270–81. doi: 10.1097/CCM.0000000000000704 25377017

39. Piers RD, Azoulay E, Ricou B, DeKeyser Ganz F, Max A, Michalsen A, et al. Inappropriate Care in European ICUs Confronting views from nurses and junior and senior physicians. Chest 2014; 146(2): 267–275. doi: 10.1378/chest.14-0256 24832567

40. Ferrand E, Robert R, Ingrand P, Lemaire F. Withholding and withdrawal of life support in intensive care units in France: a prospective survey. French LATAREA Group. Lancet 2001; 357(9249): 9–14. doi: 10.1016/s0140-6736(00)03564-9 11197395

41. Azoulay E, Metnitz B, Sprung CL, Timsit JF, Lemaire F, Bauer P, et al. End-of-life practices in 282 intensive care units: data from the SAPS 3 database. Intensive Care Med 2009; 35(4): 623–30. doi: 10.1007/s00134-008-1310-6 18850088

Článek vyšel v časopise


2019 Číslo 11