Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units

Olivier Lesieur, Maxime Leloup, Frédéric Gonzalez, Marie-France Mamzer, EPILAT study group, Olivier Lesieur, Maxime Leloup, Frédéric Gonzalez, Marie-France Mamzer, Olivier Baudin, Martine Nyunga, Julien Charpentier, Louis Louis Dubost, Laurent Martin Lefevre, Frédéric Guillaume, Marina Thirion, Patrice Tirot, Pascal Beuret, Maud Jonas, Mickaël Moriconi, Jean Philippe Rigaud, Jean Pierre Quenot, Danielle Reuter, René Robert, Nicolas Pichon, Thierry Boulain, Renaud Chouquer, Antoine Ausseur, Fabrice Bruneel, Caroline Perreau, Benjamin Zuber, Alexandra Brionne, Benoit Giraud, Xavier Tchenio, Gérald Viquesnel, Cécile Lory, Malika Benrezkallah, Diane Friedman, Jean Paul Gouello, Saint Malo, Thierry Vanderlinden, Michel Pinsard, Benoit Misset, Emmanuel Antok, Fabienne Plouvier, Didier Thevenin, Marc-Olivier Fischer, Olivier Gontier, Marc Vinclair, Christian Mirolo, François Nicolas, Willy-Serge Mfam, David Petitpas, Olivier Lesieur, Maxime Leloup, Frédéric Gonzalez, Marie-France Mamzer, EPILAT study group, Olivier Lesieur, Maxime Leloup, Frédéric Gonzalez, Marie-France Mamzer, Olivier Baudin, Martine Nyunga, Julien Charpentier, Louis Louis Dubost, Laurent Martin Lefevre, Frédéric Guillaume, Marina Thirion, Patrice Tirot, Pascal Beuret, Maud Jonas, Mickaël Moriconi, Jean Philippe Rigaud, Jean Pierre Quenot, Danielle Reuter, René Robert, Nicolas Pichon, Thierry Boulain, Renaud Chouquer, Antoine Ausseur, Fabrice Bruneel, Caroline Perreau, Benjamin Zuber, Alexandra Brionne, Benoit Giraud, Xavier Tchenio, Gérald Viquesnel, Cécile Lory, Malika Benrezkallah, Diane Friedman, Jean Paul Gouello, Saint Malo, Thierry Vanderlinden, Michel Pinsard, Benoit Misset, Emmanuel Antok, Fabienne Plouvier, Didier Thevenin, Marc-Olivier Fischer, Olivier Gontier, Marc Vinclair, Christian Mirolo, François Nicolas, Willy-Serge Mfam, David Petitpas

Abstract

Background: In France, decisions to limit treatment fall under the Leonetti law adopted in 2005. Leading figures from the French world of politics, science, and justice recently claimed for amendments to the law, considering it incomplete. This study, conducted before any legislative change, aimed to investigate the procedural aspects of withholding/withdrawing treatment in French ICUs and their adequacy with the existing law.

Methods: The characteristics of patients qualified for a withholding/withdrawal procedure were prospectively collected in 43 French ICUs. The study period (60 or 90 days under normal operating conditions) took place in the first half of 2013.

Results: During the study period, 777 (14 %) of 5589 admitted patients and 584 (52 %) of 1132 patients dying in the ICU had their treatment withheld or withdrawn. Whereas 344 patients had treatment(s) withheld (i.e., not started or not increased if already engaged), 433 had one or more treatment(s) withdrawn. Withdrawal of treatment was applied in 156 of 223 (70 %) brain-injured patients, compared to 277 of 554 (50 %) patients with other reasons for admission (p < 0.01). At the time of the decision-making, the patient's wishes were known in 181 (23 %) of the 777 cases in one or more different way(s): 73 (9.4 %) from the patient, 10 (1.3 %) by advance directives, 10 (1.3 %) through a designated trusted person, and 108 (13.9 %) reported by the family or close relatives. An external consultant was involved in less than half of all decisions (356 of 777, 46 %). Of the 777 patients qualified for a withholding/withdrawal procedure, 133 (17 %) were discharged alive from the hospital (126 after withholding, 7 after withdrawal).

Conclusions: More than half of deaths in the study population occurred after a decision to withhold or withdraw treatment. Among patients under withholding/withdrawal procedures, brain-injured subjects were more likely to undergo a withdrawal procedure. The prevalence of advance directives and designated trusted persons was low. Because patients' preferences were unknown in more than three quarters of cases, decisions remained primarily based on medical judgment. Limitations, especially withholding of treatment, did not preclude survival and hospital discharge.

Figures

Fig. 1
Fig. 1
Flow chart. WhWd withhold or withdraw treatment, ICU intensive care unit
Fig. 2
Fig. 2
Characteristics of patients admitted over the study period. WhWd withhold or withdraw treatment, Alive discharged alive from the ICU, CDD circulatory determination of death, BDD brain determination of death, deceased in the ICU, M/F sex ratio, SAPS Simplified Acute Physiology Score, LOS length of stay
Fig. 3
Fig. 3
Relationship between SAPS II (a), mortality rate (b), and WhWd decision rate among the 43 participating ICUs. SAPS Simplified Acute Physiology Score, WhWd withhold or withdraw treatment, ICU intensive care unit
Fig. 4
Fig. 4
WhWd measures implemented separating “do not start,” “do not increase,” (a) and “stop” (b) orders. WhWd withhold or withdraw treatment, Wd withdraw treatment

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