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 decision-makers, 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-not-resuscitate orders, with the remaining half almost equally split between withholding and withdrawing treatment. Units less inclined to limit treatments (odds ratio