• Ritesh Maharaj, David A Harrison, and Kathryn Rowan.
• Department of Health Policy, London School of Economics and Political Science, London, United Kingdom.
• Crit. Care Med. 2022 Apr 1; 50 (4): 576585576-585.

ObjectivesDifferences in decisions to limit life-sustaining therapy are often supported by perceptions that patients receive unnecessary and expensive treatment which provide negligible survival benefit. However, the assumption behind those beliefs-that is, that life-sustaining therapy provides no significant marginal survival benefit-remains unproven. Our objective was to quantify the effects of variations in decisions to withdraw or withhold life-sustaining treatment on 180-day mortality in critically ill patients.DesignRetrospective observational cohort study of a national clinical database.SettingAdult ICUs participating in the Intensive Care National Audit and Research Center Case Mix Program in the United Kingdom.PatientsAdult patients admitted to general ICUs between April 1, 2009, and March 31, 2016.Measurements And Main ResultsDuring the study period, 795,721 patients were admitted to 247 ICUs across the United Kingdom. A decision to withdraw or withhold life-sustaining treatment was made for 92,327 patients (11.6%). A multilevel model approach was used to estimate ICU-level practice variation. The ICU-level practice variation was then used as an instrument to measure the effects of decision to withdraw or withhold life-sustaining treatment on 180-day mortality. The marginal population was estimated to be 5.9% of the total cohort. A decision to withdraw or withhold life-sustaining treatment was associated with a marginal increase in 180-day mortality of 25.6% (95% CI, 23.2-27.9%).ConclusionsDecision to withdraw or withhold life-sustaining treatment in critically ill adults in the United Kingdom was associated with increased 180-day mortality in the marginal patients. The increased mortality from a decision to withdraw or withhold life-sustaining treatment in the marginal patient may be informative when establishing patients' preferences and evaluating the cost-effectiveness of intensive treatments.Copyright © 2022 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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