Amacher Simon A, Baumann Sira M, Kliem Paulina S C, Vock Dominik, Erne Yasmin, Grzonka Pascale, Berger Sebastian, Lohri Martin, Hunziker Sabina, Gebhard Caroline E, Nebiker Mathias, Cioccari Luca, Sutter Raoul
Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland.
Department of Anesthesiology and Intensive Care Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
Ann Intensive Care. 2025 Jul 14;15(1):94. doi: 10.1186/s13613-025-01518-z.
Advance directives (ADs) are legally binding documents outlining individual preferences for medical care in the event of incapacitation. Evidence regarding their significance and implementation in critical care is scarce. Thus, this retrospective cohort study assesses sex differences in ADs' frequency, content, clinical translation, and associated outcomes in critically ill adults. The study was performed in two interdisciplinary tertiary Swiss intensive care units (ICUs). It included patients with ADs treated in the ICUs for > 48 h. The primary endpoint was the frequency of ADs. Secondary endpoints included the content of ADs, sex differences in baseline and treatment characteristics, the clinical implementation of ADs, and in-hospital outcomes.
5242 patients were treated for > 48 h in the ICUs, of which 313 (6.0%) had ADs (124 females [6.8% of 1813 females] and 189 males [5.5% of 3429 males], p = 0.054). No sex-related differences were observed regarding baseline characteristics except that females with ADs were more frequently single, divorced, or widowed (57% vs. 37%, p = 0.001), more frequently had acute stroke as main diagnosis (13% vs. 3%, p = 0.001), and more often refused cardiopulmonary resuscitation (CPR) (42% vs. 25%, p = 0.002) than males with ADs. In multivariable analyses, female sex was associated with refusing CPR independent of relationship status. Compared to males, females' ADs were more frequently violated (24% vs. 10%, p < 0.001), primarily by receiving unwanted treatments (24% vs. 8%, p < 0.001) and/or undesired ICU admission (10.5% vs 2.1%, p = 0.002). Despite these differences, treatment adaptations during intensive care, in-hospital outcomes, and discharge destinations did not differ between sexes.
This study revealed sex disparities in the content and translation of ADs between females and males admitted to ICUs. Females' ADs were more frequently violated, indicating a potential sex bias in the interpretation and translation of ADs in critical care. Clinicians must remain vigilant against violations of ADs and strive to deliver equitable care. Further prospective research is needed to investigate the causes of disparities in ICU end-of-life decision-making, integrating both qualitative and quantitative measures, to ensure equal treatment for all patients, regardless of sex or gender.
预立医疗指示（ADs）是具有法律约束力的文件，概述了在丧失行为能力时个人对医疗护理的偏好。关于其在重症监护中的重要性和实施情况的证据很少。因此，这项回顾性队列研究评估了重症成年患者中ADs的频率、内容、临床转化及相关结果的性别差异。该研究在瑞士的两个跨学科三级重症监护病房（ICU）进行。纳入在ICU接受治疗超过48小时且有ADs的患者。主要终点是ADs的频率。次要终点包括ADs的内容、基线和治疗特征的性别差异、ADs的临床实施情况以及住院结局。
5242例患者在ICU接受了超过48小时的治疗，其中313例（6.0%）有ADs（124例女性[占1813例女性的6.8%]和189例男性[占3429例男性的5.5%]，p = 0.054）。除了有ADs的女性更频繁地单身、离异或丧偶（57%对37%，p = 0.001），更频繁地以急性中风作为主要诊断（13%对3%，p = 0.001），以及比有ADs的男性更常拒绝心肺复苏（CPR）（42%对25%，p = 0.002）外，未观察到基线特征方面的性别差异。在多变量分析中，女性性别与拒绝CPR相关，与关系状态无关。与男性相比，女性的ADs更频繁地被违反（24%对10%，p < 0.001），主要是接受了不必要的治疗（24%对8%，p < 0.001）和/或意外入住ICU（10.5%对2.1%，p = 0.002）。尽管存在这些差异，但重症监护期间的治疗调整情况、住院结局和出院目的地在性别之间并无差异。
本研究揭示了入住ICU的女性和男性在ADs的内容和转化方面存在性别差异。女性的ADs更频繁地被违反，表明在重症监护中对ADs的解释和转化可能存在性别偏见。临床医生必须对违反ADs的情况保持警惕，并努力提供公平的护理。需要进一步开展前瞻性研究，综合定性和定量措施，调查ICU临终决策差异的原因，以确保所有患者，无论性别，都能得到平等对待。
