Prevalence, Timing, and Predictors of Patients Who Had New and/or Updated Goals of Care While in the ICU: A Multicenter Retrospective Study.

Abstract

Objectives: Timely documentation of patient-concordant goals of care (GOC) in the ICU aims to promote patient autonomy and patient-centered care where the harms of interventions outweigh the potential benefits. This study examined the prevalence, timing, and predictors of ICU patients undergoing new and updated GOC documentation events while in the ICU.

Design: Multicenter retrospective study.

Setting and patients: All adults admitted to four ICUs from July 1, 2023, to December 31, 2023.

Interventions: None.

Main outcomes: The primary outcome was to determine the prevalence, timing, and predictors of new-GOC and updated-GOC documentation events following ICU admission.

Measurements and main results: We used multivariable logistic regression to identify predictors for new-GOC or updated-GOC documentation events using a backward stepwise elimination. Of the 2130 patients included, 13.3% ( n = 284) had a new-GOC documentation event, and 16.3% ( n = 346) had an updated-GOC documentation event. New-GOC events occurred sooner than updated-GOC events (median [interquartile range]: 18.3 [7.8-70.5] vs 73.7 [22.7-157.8] hr). Factors associated with GOC documentation events included age (odds ratio [OR] = 1.02, 95% CI, 1.01-1.03), frailty (OR = 1.30; 95% CI, 1.16-1.46), Sequential Organ Failure Assessment (SOFA) (OR = 1.23, 95% CI, 1.17-1.29), metastatic cancer (OR = 3.69, 95% CI, 2.17-6.26), ICU admission post medical emergency team review (OR = 1.94, 95% CI, 1.40-2.69), and cardiac arrest (OR = 2.23, 95% CI, 1.22-4.06) and if pre-ICU GOC had established treatment limitations, namely selective treatment goals (OR = 4.33, 95% CI, 3.18-5.90) or comfort-based treatment goals (OR = 7.66, 95% CI, 2.72-21.61). Apart from SOFA, all other factors remained significantly associated with GOC documentation events, even after accounting for ICU mortality as a competing outcome.

Conclusions: Almost 30% of patients had new- or updated-GOC documentation events while in ICU. Increasing age, higher SOFA scores, metastatic cancer, frailty, cardiac arrest, and ICU admission post-MET review predicted GOC changes while in ICU.