Validation of END-of-life ScorING-system to identify the dying patient: a prospective analysis

Gianluca Villa, Timothy Amass, Rosa Giua, Iacopo Lanini, Cosimo Chelazzi, Lorenzo Tofani, Rory McFadden, A Raffaele De Gaudio, Sean OMahony, Mitchell M Levy, Stefano Romagnoli, Gianluca Villa, Timothy Amass, Rosa Giua, Iacopo Lanini, Cosimo Chelazzi, Lorenzo Tofani, Rory McFadden, A Raffaele De Gaudio, Sean OMahony, Mitchell M Levy, Stefano Romagnoli

Abstract

Background: The "END-of-Life ScorING-System" (ENDING-S) was previously developed to identify patients at high-risk of dying in the ICU and to facilitate a practical integration between palliative and intensive care. The aim of this study is to prospectively validate ENDING-S in a cohort of long-term critical care patients.

Materials and methods: Adult long-term ICU patients (with a length-of-stay> 4 days) were considered for this prospective multicenter observational study. ENDING-S and SOFA score were calculated daily and evaluated against the patient's ICU outcome. The predictive properties were evaluated through a receiver operating characteristic (ROC) analysis.

Results: Two hundred twenty patients were enrolled for this study. Among these, 21.46% died during the ICU stay. ENDING-S correctly predicted the ICU outcome in 71.4% of patients. Sensitivity, specificity, positive and negative predictive values associated with the previously identified ENDING-S cut-off of 11.5 were 68.1, 72.3, 60 and 89.3%, respectively. ROC-AUC for outcome prediction was 0.79 for ENDING-S and 0.88 for SOFA in this cohort.

Conclusions: ENDING-S, while not as accurately as in the pilot study, demonstrated acceptable discrimination properties in identifying long-term ICU patients at very high-risk of dying. ENDING-S may be a useful tool aimed at facilitating a practical integration between palliative, end-of-life and intensive care.

Trial registration: Clinicaltrials.gov Identifier: NCT02875912; First registration August 4, 2016.

Keywords: End of life; Scoring system; intensive care unit; palliative care.

Conflict of interest statement

We have the following interests: GV received from Baxter honoraria for lectures, from Pall International support for travel expenses, hotel accommodations, and registration to meetings. SR received from Baxter, Orion Pharma, and Vygon honoraria for lectures, from ICU Medical, MSD and Medtronic grants for consultancy, form Baxter, BBraun, Pall International, and Vygon support for travel expenses, hotel accommodations, and registration to meetings. CC received support for meetings (travels, hotel accommodations, and/or registration) by BBraun, Astellas, MSD, Pfizer, Pall International, Baxter, and Orion Pharma, for lectures by Orion Pharma. ARDG received research grants from MSD Italia, Baxter, Pall international. There are no patents, products in development or marketed products to declare. This does not alter our adherence to all the journal policies.

Figures

Fig. 1
Fig. 1
The enrollment process. Over the entire population potentially eligible for this prospective study, 194 patients were excluded because admitted in the ICU for comfort measure only (CMO), for lack of family members (required for the qualitative analysis of the study, data not presented), or because pregnant or prisoner. In order to consider only “long term” ICU patients, those with an ICU length of stay (LoS) 

Fig. 2

Likelihood of ICU Death. ROC…

Fig. 2

Likelihood of ICU Death. ROC curves for patients’ outcome discrimination for both ENDING-S…

Fig. 2
Likelihood of ICU Death. ROC curves for patients’ outcome discrimination for both ENDING-S (Panel a, ROC-AUC 0.79) and SOFA score (Panel b, ROC-AUC 0.88)

Fig. 3

Probability of ICU Death as…

Fig. 3

Probability of ICU Death as compared to increasing values of ENDING-S (panel a…

Fig. 3
Probability of ICU Death as compared to increasing values of ENDING-S (panel a) and SOFA score (panel b). For each patient, the higher the ENDING-s or SOFA score, the higher the probability of ICU death, the higher the amount of palliative care interventions (in green) that should be integrated with intensive care treatment (in blue). Palliative care and intensive care should not be mutually exclusive; they should instead integrate each-other during the entire course of the patient’s disease from the diagnosis and the initial organ dysfunction to the occurrence of multiorgan failure and end-of-life condition (within the dashed line). An appropriate scoring system should be characterized by a slope in score/outcome probability able to promote intensive care and palliative care integration continuously, and across different levels of patient’s severity
Fig. 2
Fig. 2
Likelihood of ICU Death. ROC curves for patients’ outcome discrimination for both ENDING-S (Panel a, ROC-AUC 0.79) and SOFA score (Panel b, ROC-AUC 0.88)
Fig. 3
Fig. 3
Probability of ICU Death as compared to increasing values of ENDING-S (panel a) and SOFA score (panel b). For each patient, the higher the ENDING-s or SOFA score, the higher the probability of ICU death, the higher the amount of palliative care interventions (in green) that should be integrated with intensive care treatment (in blue). Palliative care and intensive care should not be mutually exclusive; they should instead integrate each-other during the entire course of the patient’s disease from the diagnosis and the initial organ dysfunction to the occurrence of multiorgan failure and end-of-life condition (within the dashed line). An appropriate scoring system should be characterized by a slope in score/outcome probability able to promote intensive care and palliative care integration continuously, and across different levels of patient’s severity

References

    1. Bertolini G, Boffelli S, Malacarne P, Peta M, Marchesi M, Barbisan C, et al. End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units. Intensive Care Med. 2010;36(9):1495–1504. doi: 10.1007/s00134-010-1910-9.
    1. Angus DC, Barnato AE, Linde-Zwirble 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):638–643. doi: 10.1097/01.CCM.0000114816.62331.08.
    1. Orsi L, Gristina GR. The right choice at the right time. Minerva Anestesiol. Italy. 2017;83(5):436–439.
    1. Gristina GR, De Gaudio R, Mazzon D, Curtis JR. End of life care in Italian intensive care units: where are we now? Minerva Anestesiol. 2011;77(9):911–920.
    1. Amass TH, Villa G, OMahony S, Badger JM, McFadden R, Walsh T, et al. Family Care rituals in the ICU to reduce symptoms of post-traumatic stress disorder in family members-a multicenter, multinational, before-and-after intervention trial. Crit Care Med United States. 2020;48(2):176–184. doi: 10.1097/CCM.0000000000004113.
    1. Vuong C, Kittelson S, McCullough L, Yingwei Y, Hartjes T. Implementing primary palliative care best practices in critical care with the Care and Communication Bundle. BMJ open Qual. 2019;8(3):e000513. doi: 10.1136/bmjoq-2018-000513.
    1. Giannoni C, Chelazzi C, Villa G, De Gaudio AR. Organ dysfunction scores in ICU. Trends Anaesth Crit Care. 2013;3(3):89–96. doi: 10.1016/j.tacc.2013.01.008.
    1. Luce JM. End-of-life decision making in the intensive care unit. Am J Respir Crit Care Med. 2010;182(1):6–11. Available from: . [cited 2012 Nov 9].
    1. Fischer SM, Gozansky WS, Sauaia A, Min S-J, Kutner JS, Kramer A. A practical tool to identify patients who may benefit from a palliative approach: the CARING criteria. J Pain Symptom Manage. 2006;31(4):285–292. doi: 10.1016/j.jpainsymman.2005.08.012.
    1. Frick S, Uehlinger DE, Zuercher Zenklusen RM. Medical futility: predicting outcome of intensive care unit patients by nurses and doctors--a prospective comparative study. Crit Care Med. 2003 ;31(2):456–61. Available from: . [cited 2014 Jun 2].
    1. Villa G, De Gaudio AR, Falsini S, Lanini I, Curtis JR. Development of END-of-life ScorING-system to identify critically ill patients after initial critical care who are highly likely to die: a pilot study. Minerva Anestesiol Italy. 2015;81(12):1318–1328.
    1. Teike Luthi F, Mabire C, Rosselet Amoussou J, Bernard M, Borasio GD, Ramelet A-S. Instruments for the identification of patients in need of palliative care: a systematic review protocol of measurement properties. Australia: JBI database Syst Rev Implement reports; 2019.
    1. Hallen SAM, Ba NAMH, Mph LB, Ms CMG, Han PKJ, Mph MA. Physicians ’ perceptions of the value of prognostic models : the benefits and risks of prognostic confidence. 2014. pp. 1–12.
    1. Curtis JR, Nielsen EL, Treece PD, Downey L, Dotolo D, Shannon SE, et al. Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial. Am J Respir Crit Care Med. 2011;183(3):348–355. doi: 10.1164/rccm.201006-1004OC.
    1. Penrod J, Pronovost P, Livote E, Puntillo K, Walker A, Wallenstein S, et al. Meeting standards of high-quality intensive care unit palliative care: clinical performance and predictors. Crit Care Med. 2012;40(4):1105–1112. doi: 10.1097/CCM.0b013e3182374a50.
    1. Bradley CT, Brasel KJ. Developing guidelines that identify patients who would benefit from palliative care services in the surgical intensive care unit. Crit Care Med. 2009;37(3):946–950. doi: 10.1097/CCM.0b013e3181968f68.
    1. Cohen SL, Sjokvist P, Lippert A, Phelan D. End-of-Life Practices in European. Units: The Ethicus Study. JAMA. 2003;290(6):790–7.
    1. Sprung C, Cohen S, Sjokvist P, Baras M, Bulow H, Hovilehto S, et al. End-of-life practices in European intensive care units: the Ethicus study. JAMA. 2003;290(6):790–797. doi: 10.1001/jama.290.6.790.
    1. DeCato TW, Engelberg RA, Downey L, Nielsen EL, Treece PD, Back AL, et al. Hospital variation and temporal trends in palliative and end-of-life care in the ICU. Crit Care Med. 2013;41(6):1405–1411. doi: 10.1097/CCM.0b013e318287f289.
    1. Naib T, Lahewala S, Arora S, Gidwani U. Palliative care in the cardiac intensive care unit. Am J Cardiol. 2015;115(5):687–690. doi: 10.1016/j.amjcard.2014.12.023.
    1. de Barros Gulini JEHM, do Nascimento ERP, Moritz RD, de Oliveira Vargas MA, Matte DL, Cabral RP. Predictors of death in an Intensive Care Unit: contribution to the palliative approach TT - Fatores preditores de óbito em Unidade de Terapia Intensiva: contribuição para a abordagem paliativista. Rev Esc Enferm USP. 2018;52:e03342. doi: 10.1590/s1980-220x2017023203342.
    1. Romano AM, Gade KE, Nielsen G, Havard R, Harrison JHJ, Barclay J, et al. Early palliative Care reduces end-of-life intensive Care unit (ICU) use but not ICU course in patients with advanced cancer. Oncologist United States. 2017;22(3):318–323. doi: 10.1634/theoncologist.2016-0227.

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