Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study

BACKGROUND

Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches.

METHODS

This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality.

RESULTS

There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis.

CONCLUSIONS

Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.

Stroke prevention in elderly patients with atrial fibrillation

BACKGROUND

The prevalence of atrial fibrillation increases with age. Atrial fibrillation has been shown to be a significant risk factor for stroke in the elderly. Anticoagulation is effective in preventing stroke in geriatric patients with atrial fibrillation, yet many elderly patients with atrial fibrillation are not anticoagulated.

OBJECTIVES

This study aims to determine the prevalence of atrial fibrillation in an inpatient population of a geriatric unit and explores the usage of anticoagulants in those patients diagnosed with atrial fibrillation.

METHODS

Consecutive admissions to a geriatric unit were screened with an electrocardiogram to establish a diagnosis of atrial fibrillation. Those with atrial fibrillation were evaluated for risk factors for stroke and for contraindications for anticoagulation. Documentation of reasons for withholding anticoagulation was also examined.

RESULTS

Five hundred and six consecutive inpatient admissions were screened. Fifty-six patients had atrial fibrillation (11.1%). Forty of these were known cases of atrial fibrillation whereas sixteen were newly diagnosed. There were 22 (39.3%) males and 34 (60.7%) females. The mean age was 83.3 years (S.D. 6.8). The four most common risk concomitant factors for stroke were age above 75 years (54, 96.4%), hypertension (41, 73.2%), congestive cardiac failure (28, 50%), and a history of strokes (20, 35.7%). Fifty-five (98.2%) patients had at least two other concomitant risk factors for stroke. On discharge, only nine (16.1%) out of 56 patients were anticoagulated. Anticoagulation was withheld because of contraindications in 44 (78.6%) patients and because of patients' objection to anticoagulation in 3 (5.3%) patients. The two most common reasons for withholding anticoagulation were the risk of recurrent falls (18, 38.3%) and peptic ulcer disease (15, 31.9%).

CONCLUSIONS

The prevalence rate of atrial fibrillation in elderly inpatients was found to be 11.1%. Most of the elderly with atrial fibrillation had multiple concomitant risk factors for stroke and would benefit from anticoagulant therapy. However, in the majority, anticoagulation was withheld because of contraindications (78.6%) and patients' objection to anticoagulation (5.3%).