Death in two Canadian intensive care units: Institutional difference and changes over time

Objective: To study and compare the mode of death in two different institut ions' intensive care units (ICUs) for the two time periods, 1988 and 1993. Design: Retrospective chart review. Setting: Medical/surgical/trauma ICUs in two tertiary care teaching hospita ls. Patients: Patients dying in the medical/surgical/trauma ICUs between Januar y 1, 1988 and December 31, 1988; and January 1, 1993 and December 31, 1993, Data collection included demographics, origin of admission, date of ICU ad mission, date of death, Acute Physiology and Chronic Health Evaluation (APA CHE) III diagnostic categories, APACHE II physiologic variables, organ syst em failures present at the time of admission and 24 hrs before death, and m ode of dying. APACHE II scores and mortality risk were calculated. Data ana lysis included a multiple analysis of variance to assess overall effect, wi th subsequent analyses of variance to assess the effect of institution and year on each individual dependent variable. All results are reported as mea n +/- SEM values. Results: A total of 439 charts were reviewed. Gender, age, and origin of ad mission were not different between the 2 yrs or the two institutions. Mean APACHE II scores and organ system failures were lower at Hospital A in 1998 vs. Hospital B, as was predicted mortality. These factors increased at Hos pital A in 1993 and were similar to those at Hospital B. Withdrawal of supp ort was much more common in 1993 than 1988 at both institutions (43% at Hos pital A and 46% at Hospital B in 1988 vs. 66% at A and 80% at B in 1993), i ncreasing to a greater extent in 1993 at Hospital B (p < .05), Length of st ay in the ICU was significantly longer at Hospital A than at Hospital B in 1988 (9.4 +/- 1.4 vs, 4.3 +/- 0.6 days; p < .05) and in 1993 (8.2 +/- 2.9 v s. 3.8 +/- 0.5 days; p < .05). Conclusions: There has been an increase in withdrawal of life support, in r ecent years, at both the institutions studied. Differences exist between in stitutions with respect to end-of-life decisions in the ICU, These differen ces are likely representative of widely prevalent regional differences and are the result of many factors.