Decision-making and outcomes of prolonged ICU stays in seriously ill patients

BACKGROUND: Despite concern about the high costs and the uncertain benefit of prolonged treatment in the intensive care unit (ICU), there has been lit tle research examining decision-making and outcomes for patients with prolo nged ICU stays. OBJECTIVES: To evaluate decision-making and outcomes for seriously ill pati ents with an ICU stay of at least 14 days. DESIGN: A prospective cohort study. SETTING: Five teaching hospitals. PARTICIPANTS: Seriously ill patients enrolled in the Study To Understand Pr ognoses and Preferences for Risks and Outcomes of Treatments (SUPPORT). MEASUREMENT: Patients, their surrogate decisionmakers, and their physicians were interviewed about prognosis, communication, and goals of medical care . Based on age, diagnoses, comorbid illnesses, and acute physiology data, t he SUPPORT Prognostic Model provided estimates of 6-month survival on study days 1, 3, 7, and 14. Hospital costs were estimated from hospital billing data. RESULTS: Of the 9105 patients enrolled in SUPPORT, 1494 (16%) had ICU stays of 14 days or longer. The median length of stay in an ICU was 4 days for t he entire SUPPORT cohort and 35 days for patients who were treated in an IC U for 14 days or longer. Median hospital costs were $76,501 for patients wh o had ICU stays 14 clays or longer and $10,916 for patients who did not hav e long ICU stays. Fifty-five Pii;percent of patients with long ICU stays ha d died by 6 months, and an additional 19% had substantial functional impair ment. Among patients with ICU stays of at least 14 days, only 20% had estim ates of 6-month survival that fell below 10% at any time during their hospi talization. For patients with long ICU stays, the mean predicted probabilit y of 6-month survival was 0.46 on study Day 3 and 0.47 on study Day 14. Few er than 40% of patients (or their surrogates) reported that their physician s had talked with them about their prognoses or preferences for life-sustai ning treatment. Among the patients who preferred a palliative approach to c are, only 29% thought that their care was consistent with that aim. Those w ho discussed their preferences for care with a physician were 1.9 times mor e likely to believe that treatment was in accord with their preferences for palliation (95% CI, 1.4-2.5). CONCLUSIONS: Prolonged ICU stays were expensive and were often followed by death or disability. Patients reported low rates of discussions with their physicians about their prognoses and preferences for life-sustaining treatm ents. Many preferred that care focus on palliation and believed that care w as inconsistent with their preferences. Patients were more likely to receiv e care consistent with their preferences if they had discussed their care p references with their physicians.