Harborview Medical Center, University of Washington, Seattle, WA, USA,
Intensive Care Med. 2015 Sep;41(9):1572-85. doi: 10.1007/s00134-015-3810-5. Epub 2015 Apr 23.
Prior studies identified high variability in prevalence of withdrawal of life-sustaining treatment in the ICU. Variability in end-of-life decision-making has been reported at many levels: between countries, ICUs, and individual intensivists. We performed a systematic review examining regional, national, inter-hospital, and inter-physician variability in withdrawal of life-sustaining treatment in the ICU.
Using a predefined search strategy, we queried three electronic databases for peer-reviewed articles addressing withdrawal of life-sustaining treatment in adult patients in the ICU. Data were analyzed for variability in prevalence of withdrawal of life-sustaining treatment. Withholding of life-sustaining treatment was also examined where information was provided. An assessment tool was developed to quantify the risk of bias in the included articles.
We identified 1284 studies, with 56 included after review. Most studies had unclear or high risk of bias, primarily due to unclear case definitions or potential confounding. The mean prevalence of withdrawal of life-sustaining treatment for patients who died varied from 0 to 84.1% between studies, with standard deviation of 23.7%. Sensitivity analysis of general ICU patients yielded similar results. Withholding also varied between 5.3 and 67.3% (mean 27.3, SD 18.5%). Substantial variability was found between world regions, countries, individual ICUs within a country, and individual intensivists within one ICU.
We identified substantial variability in the withdrawal of life-sustaining treatment across world regions and countries. Similar variability existed between ICUs within countries and even between providers within the same ICU. Further study is necessary, and could lead to interventions to improve end-of-life care in the ICU.
先前的研究表明，在重症监护病房（ICU）中，停止生命支持治疗的比例存在很大差异。在许多层面上，如国家之间、ICU 之间以及个别重症监护医师之间，都报告了临终决策存在差异。我们进行了一项系统评价，旨在研究 ICU 中停止生命支持治疗的区域性、国家性、医院间和医师间差异。
使用预先设定的搜索策略，我们在三个电子数据库中查询了关于 ICU 中成年患者停止生命支持治疗的同行评议文章。对停止生命支持治疗的比例的变异性进行了数据分析。在有信息提供的情况下，还对停止维持生命治疗的情况进行了研究。开发了一种评估工具来量化纳入文章的偏倚风险。
我们共确定了 1284 项研究，其中 56 项在审查后被纳入。大多数研究存在不明确或高偏倚风险，主要是由于不明确的病例定义或潜在的混杂因素。研究之间，死亡患者停止生命支持治疗的比例平均值从 0 到 84.1%不等，标准差为 23.7%。对普通 ICU 患者的敏感性分析得出了类似的结果。保留治疗的比例也在 5.3%到 67.3%之间（平均值为 27.3%，标准差为 18.5%）。我们发现世界各地区、国家、国家内个别 ICU 以及同一 ICU 内个别重症监护医师之间存在显著差异。
我们发现，在世界各地区和国家之间，停止生命支持治疗的比例存在很大差异。在国家内的 ICU 之间，甚至在同一 ICU 内的提供者之间，也存在类似的差异。需要进一步研究，这可能会导致干预措施的实施，以改善 ICU 中的临终关怀。
