Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe

Bernhard Wernly; Richard Rezar; Hans Flaatten; Michael Beil; Jesper Fjølner; Raphael Romano Bruno; Antonio Artigas; Bernardo Bollen Pinto; Joerg C Schefold; Malte Kelm; Sviri Sigal; Peter Vernon van Heerden; Wojciech Szczeklik; Muhammed Elhadi; Michael Joannidis; Sandra Oeyen; Georg Wolff; Brian Marsh; Finn H Andersen; Rui Moreno; Susannah Leaver; Sarah Wernly; Ariane Boumendil; Dylan W De Lange; Bertrand Guidet; Christian Jung

doi:10.1111/joim.13492

Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe

Bernhard Wernly, Richard Rezar, Hans Flaatten, Michael Beil, Jesper Fjølner, Raphael Romano Bruno, Antonio Artigas, Bernardo Bollen Pinto, Joerg C Schefold, Malte Kelm, Sviri Sigal, Peter Vernon van Heerden, Wojciech Szczeklik, Muhammed Elhadi, Michael Joannidis, Sandra Oeyen, Georg Wolff, Brian Marsh, Finn H Andersen, Rui MorenoSusannah Leaver, Sarah Wernly, Ariane Boumendil, Dylan W De Lange, Bertrand Guidet, Christian Jung

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Abstract

BACKGROUND: Previous studies reported regional differences in end-of-life care (EoLC) for critically ill patients in Europe.

OBJECTIVES: The purpose of this post-hoc analysis of the prospective multicentre COVIP study was to investigate variations in EoLC practices among older patients in intensive care units during the coronavirus disease 2019 pandemic.

METHODS: A total of 3105 critically ill patients aged 70 years and older were enrolled in this study (Central Europe: n = 1573; Northern Europe: n = 821; Southern Europe: n = 711). Generalised estimation equations were used to calculate adjusted odds ratios (aORs) to population averages. Data were adjusted for patient-specific variables (demographic, disease-specific) and health economic data (gross domestic product, health expenditure per capita). The primary outcome was any treatment limitation, and 90-day mortality was a secondary outcome.

RESULTS: The frequency of the primary endpoint (treatment limitation) was highest in Northern Europe (48%), intermediate in Central Europe (39%) and lowest in Southern Europe (24%). The likelihood for treatment limitations was lower in Southern than in Central Europe (aOR 0.39; 95% confidence interval [CI] 0.21-0.73; p = 0.004), even after multivariable adjustment, whereas no statistically significant differences were observed between Northern and Central Europe (aOR 0.57; 95%CI 0.27-1.22; p = 0.15). After multivariable adjustment, no statistically relevant mortality differences were found between Northern and Central Europe (aOR 1.29; 95%CI 0.80-2.09; p = 0.30) or between Southern and Central Europe (aOR 1.07; 95%CI 0.66-1.73; p = 0.78).

CONCLUSION: This study shows a north-to-south gradient in rates of treatment limitation in Europe, highlighting the heterogeneity of EoLC practices across countries. However, mortality rates were not affected by these results.

Original language	English
Pages (from-to)	438-449
Number of pages	12
Journal	Journal of Internal Medicine
Volume	292
Issue number	3
DOIs	https://doi.org/10.1111/joim.13492
Publication status	Published - Sept 2022

Keywords

COVID-19
critical care
frail elderly
public health systems research
resuscitation orders

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Journal of Internal Medicine - 2022 - Wernly - Variations in end‐of‐life care practices in older critically ill patientsFinal published version, 586 KBLicence: CC BY-NC-ND

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Wernly, B., Rezar, R., Flaatten, H., Beil, M., Fjølner, J., Bruno, R. R., Artigas, A., Pinto, B. B., Schefold, J. C., Kelm, M., Sigal, S., van Heerden, P. V., Szczeklik, W., Elhadi, M., Joannidis, M., Oeyen, S., Wolff, G., Marsh, B., Andersen, F. H., ... Jung, C. (2022). Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe. Journal of Internal Medicine, 292(3), 438-449. https://doi.org/10.1111/joim.13492

@article{4dabc7263b044a9a8024f9d7087ee853,

title = "Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe",

abstract = "BACKGROUND: Previous studies reported regional differences in end-of-life care (EoLC) for critically ill patients in Europe.OBJECTIVES: The purpose of this post-hoc analysis of the prospective multicentre COVIP study was to investigate variations in EoLC practices among older patients in intensive care units during the coronavirus disease 2019 pandemic.METHODS: A total of 3105 critically ill patients aged 70 years and older were enrolled in this study (Central Europe: n = 1573; Northern Europe: n = 821; Southern Europe: n = 711). Generalised estimation equations were used to calculate adjusted odds ratios (aORs) to population averages. Data were adjusted for patient-specific variables (demographic, disease-specific) and health economic data (gross domestic product, health expenditure per capita). The primary outcome was any treatment limitation, and 90-day mortality was a secondary outcome.RESULTS: The frequency of the primary endpoint (treatment limitation) was highest in Northern Europe (48%), intermediate in Central Europe (39%) and lowest in Southern Europe (24%). The likelihood for treatment limitations was lower in Southern than in Central Europe (aOR 0.39; 95% confidence interval [CI] 0.21-0.73; p = 0.004), even after multivariable adjustment, whereas no statistically significant differences were observed between Northern and Central Europe (aOR 0.57; 95%CI 0.27-1.22; p = 0.15). After multivariable adjustment, no statistically relevant mortality differences were found between Northern and Central Europe (aOR 1.29; 95%CI 0.80-2.09; p = 0.30) or between Southern and Central Europe (aOR 1.07; 95%CI 0.66-1.73; p = 0.78).CONCLUSION: This study shows a north-to-south gradient in rates of treatment limitation in Europe, highlighting the heterogeneity of EoLC practices across countries. However, mortality rates were not affected by these results.",

keywords = "COVID-19, critical care, frail elderly, public health systems research, resuscitation orders",

author = "Bernhard Wernly and Richard Rezar and Hans Flaatten and Michael Beil and Jesper Fj{\o}lner and Bruno, {Raphael Romano} and Antonio Artigas and Pinto, {Bernardo Bollen} and Schefold, {Joerg C} and Malte Kelm and Sviri Sigal and {van Heerden}, {Peter Vernon} and Wojciech Szczeklik and Muhammed Elhadi and Michael Joannidis and Sandra Oeyen and Georg Wolff and Brian Marsh and Andersen, {Finn H} and Rui Moreno and Susannah Leaver and Sarah Wernly and Ariane Boumendil and {De Lange}, {Dylan W} and Bertrand Guidet and Christian Jung",

note = "Funding Information: J.C.S. (full departmental disclosure) reports grants from Orion Pharma, Abbott Nutrition International, B. Braun Medical AG, CSEM AG, Edwards Lifesciences Services GmbH, Kenta Biotech Ltd, Maquet Critical Care AB, Omnicare Clinical Research AG, Nestle, Pierre Fabre Pharma AG, Pfizer, Bard Medica S.A., Abbott AG, Anandic Medical Systems, Pan Gas AG Healthcare, Bracco, Hamilton Medical AG, Fresenius Kabi, Getinge Group Maquet AG, Dr{\"a}ger AG, Teleflex Medical GmbH, Glaxo Smith Kline, Merck Sharp and Dohme AG, Eli Lilly and Company, Baxter, Astellas, Astra Zeneca, CSL Behring, Novartis, Covidien, Phagenesis and Nycomed outside of the submitted work. The money was paid into departmental funds. No personal financial gain applied. The other authors declare that they have no conflict of interests. Publisher Copyright: {\textcopyright} 2022 The Authors. Journal of Internal Medicine published by John Wiley & Sons Ltd on behalf of Association for Publication of The Journal of Internal Medicine.",

year = "2022",

month = sep,

doi = "10.1111/joim.13492",

language = "English",

volume = "292",

pages = "438--449",

journal = "Journal of Internal Medicine",

issn = "0954-6820",

publisher = "Wiley-Blackwell",

number = "3",

}

Wernly, B, Rezar, R, Flaatten, H, Beil, M, Fjølner, J, Bruno, RR, Artigas, A, Pinto, BB, Schefold, JC, Kelm, M, Sigal, S, van Heerden, PV, Szczeklik, W, Elhadi, M, Joannidis, M, Oeyen, S, Wolff, G, Marsh, B, Andersen, FH, Moreno, R, Leaver, S, Wernly, S, Boumendil, A, De Lange, DW, Guidet, B & Jung, C 2022, 'Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe', Journal of Internal Medicine, vol. 292, no. 3, pp. 438-449. https://doi.org/10.1111/joim.13492

TY - JOUR

T1 - Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe

AU - Wernly, Bernhard

AU - Rezar, Richard

AU - Flaatten, Hans

AU - Beil, Michael

AU - Fjølner, Jesper

AU - Bruno, Raphael Romano

AU - Artigas, Antonio

AU - Pinto, Bernardo Bollen

AU - Schefold, Joerg C

AU - Kelm, Malte

AU - Sigal, Sviri

AU - van Heerden, Peter Vernon

AU - Szczeklik, Wojciech

AU - Elhadi, Muhammed

AU - Joannidis, Michael

AU - Oeyen, Sandra

AU - Wolff, Georg

AU - Marsh, Brian

AU - Andersen, Finn H

AU - Moreno, Rui

AU - Leaver, Susannah

AU - Wernly, Sarah

AU - Boumendil, Ariane

AU - De Lange, Dylan W

AU - Guidet, Bertrand

AU - Jung, Christian

N1 - Funding Information: J.C.S. (full departmental disclosure) reports grants from Orion Pharma, Abbott Nutrition International, B. Braun Medical AG, CSEM AG, Edwards Lifesciences Services GmbH, Kenta Biotech Ltd, Maquet Critical Care AB, Omnicare Clinical Research AG, Nestle, Pierre Fabre Pharma AG, Pfizer, Bard Medica S.A., Abbott AG, Anandic Medical Systems, Pan Gas AG Healthcare, Bracco, Hamilton Medical AG, Fresenius Kabi, Getinge Group Maquet AG, Dräger AG, Teleflex Medical GmbH, Glaxo Smith Kline, Merck Sharp and Dohme AG, Eli Lilly and Company, Baxter, Astellas, Astra Zeneca, CSL Behring, Novartis, Covidien, Phagenesis and Nycomed outside of the submitted work. The money was paid into departmental funds. No personal financial gain applied. The other authors declare that they have no conflict of interests. Publisher Copyright: © 2022 The Authors. Journal of Internal Medicine published by John Wiley & Sons Ltd on behalf of Association for Publication of The Journal of Internal Medicine.

PY - 2022/9

Y1 - 2022/9

N2 - BACKGROUND: Previous studies reported regional differences in end-of-life care (EoLC) for critically ill patients in Europe.OBJECTIVES: The purpose of this post-hoc analysis of the prospective multicentre COVIP study was to investigate variations in EoLC practices among older patients in intensive care units during the coronavirus disease 2019 pandemic.METHODS: A total of 3105 critically ill patients aged 70 years and older were enrolled in this study (Central Europe: n = 1573; Northern Europe: n = 821; Southern Europe: n = 711). Generalised estimation equations were used to calculate adjusted odds ratios (aORs) to population averages. Data were adjusted for patient-specific variables (demographic, disease-specific) and health economic data (gross domestic product, health expenditure per capita). The primary outcome was any treatment limitation, and 90-day mortality was a secondary outcome.RESULTS: The frequency of the primary endpoint (treatment limitation) was highest in Northern Europe (48%), intermediate in Central Europe (39%) and lowest in Southern Europe (24%). The likelihood for treatment limitations was lower in Southern than in Central Europe (aOR 0.39; 95% confidence interval [CI] 0.21-0.73; p = 0.004), even after multivariable adjustment, whereas no statistically significant differences were observed between Northern and Central Europe (aOR 0.57; 95%CI 0.27-1.22; p = 0.15). After multivariable adjustment, no statistically relevant mortality differences were found between Northern and Central Europe (aOR 1.29; 95%CI 0.80-2.09; p = 0.30) or between Southern and Central Europe (aOR 1.07; 95%CI 0.66-1.73; p = 0.78).CONCLUSION: This study shows a north-to-south gradient in rates of treatment limitation in Europe, highlighting the heterogeneity of EoLC practices across countries. However, mortality rates were not affected by these results.

AB - BACKGROUND: Previous studies reported regional differences in end-of-life care (EoLC) for critically ill patients in Europe.OBJECTIVES: The purpose of this post-hoc analysis of the prospective multicentre COVIP study was to investigate variations in EoLC practices among older patients in intensive care units during the coronavirus disease 2019 pandemic.METHODS: A total of 3105 critically ill patients aged 70 years and older were enrolled in this study (Central Europe: n = 1573; Northern Europe: n = 821; Southern Europe: n = 711). Generalised estimation equations were used to calculate adjusted odds ratios (aORs) to population averages. Data were adjusted for patient-specific variables (demographic, disease-specific) and health economic data (gross domestic product, health expenditure per capita). The primary outcome was any treatment limitation, and 90-day mortality was a secondary outcome.RESULTS: The frequency of the primary endpoint (treatment limitation) was highest in Northern Europe (48%), intermediate in Central Europe (39%) and lowest in Southern Europe (24%). The likelihood for treatment limitations was lower in Southern than in Central Europe (aOR 0.39; 95% confidence interval [CI] 0.21-0.73; p = 0.004), even after multivariable adjustment, whereas no statistically significant differences were observed between Northern and Central Europe (aOR 0.57; 95%CI 0.27-1.22; p = 0.15). After multivariable adjustment, no statistically relevant mortality differences were found between Northern and Central Europe (aOR 1.29; 95%CI 0.80-2.09; p = 0.30) or between Southern and Central Europe (aOR 1.07; 95%CI 0.66-1.73; p = 0.78).CONCLUSION: This study shows a north-to-south gradient in rates of treatment limitation in Europe, highlighting the heterogeneity of EoLC practices across countries. However, mortality rates were not affected by these results.

KW - COVID-19

KW - critical care

KW - frail elderly

KW - public health systems research

KW - resuscitation orders

UR - http://www.scopus.com/inward/record.url?scp=85134186145&partnerID=8YFLogxK

U2 - 10.1111/joim.13492

DO - 10.1111/joim.13492

M3 - Article

C2 - 35398948

SN - 0954-6820

VL - 292

SP - 438

EP - 449

JO - Journal of Internal Medicine

JF - Journal of Internal Medicine

IS - 3

ER -

Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe

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