DNR: Who Decides?

DNR: Who Decides?

Fred is 78. A retired dock-worker and Navy veteran. At 2 o clock one morning he calls his daughter Dianne, a preschool teacher. “I… Can’t….. Breathe…” He gasps down the phone. His daughter tries to conceal her own panic while telling her frail and increasingly bedridden father not to panic. She dials 911 and paramedics are soon at her fathers side. They obtain a history of congestive heart failure and administer oxygen as well as nitroglycerin and furosemide. On arrival at hospital Fred is seen immediately by an experienced emergency medicine resident who places him on a non-invasive ventilation via a tight-fitting and claustrophobic mask. The resident reads his medical record. The notes from his cardiologist paint a grim picture. Fred has an ejection fraction of 15%. The cardiologist estimates a prognosis of no more than a few months and has recommended palliative care.

Fred is admitted to the Intensive Care Unit (ICU) but fails to improve. The non-invasive ventilation is longer working. The intensivist meets with the tearful Dianne and her husband Mike. Yes, she knew that her dad was sick, and she had an inkling that his medications weren’t helping any more. She didn’t like to think about it but she knew that he would die soon. No they hadn’t spoken about it but she thinks he’d want to live for as long as possible and would value a longer life over quality of life. But no, she didn’t think he’d like to to be kept alive permanently on machines. The intensivist suggests a 48 hour trial of more aggressive treatments. Intubation, mechanical ventilation, vasopressors and inotropes in an attempt to eke another one or two percent out of his flailing heart. The intensivist recommends that if Fred’s heart stops, then he allowed to die peacefully and Cardio-Pulmonary Resuscitation (CPR) not be performed. Dianne isn’t so sure about this. Mike is adamant however – everything must be done that has a chance of prolonging Fred’s life. A day later and the situation is dire. Fred is dying – the medication and machines aren’t helping. The intensivist meets again with the family. Overwhelmed and frightened, Dianne drifts in and out “I’m so sorry…. I have some dreadful news….. Despite everything that we’re doing…. Kidneys failing, liver failing…. Your father is dying…. We should let nature take it’s course….. Comfort and dignity.” Mike interrupts to ask a question; “But if his heart stops you’ll give him the shocks and stuff, right doc?” “No” The intensivist is tactful but firm. “Fred is dying. I wish there were some other treatment I could offer that would make him live for longer but there isn’t. At this stage, with his heart and his other organs in the state that they’re in, CPR simply won’t work. The right thing to do is to make sure that Fred is comfortable and that he has you and Dianne at his side when he passes away”

Is it appropriate for physicians to unilaterally decide who should or should not have a do not resuscitate (DNR) order? Is the decision whether or not to perform CPR or not a medical decision (like whether or not to remove a patient’s gallbladder) or is a decision for the patient or their family that physicians must abide by? The issue has recently been brought to the forefront of many Canadian physician’s minds by a policy document released in 2015 by The College of Physicians and Surgeons of Ontario (CPSO). The document, entitled “Planning for and Providing Quality End-of-Life Care” has the laudable goal of improving end-of-life care for Ontarians by giving physicians guidance on best practice and it particularly emphasises the importance of communication with patients and their families.

In the section on potentially life saving and life-sustaining treatment, the policy gives guidance on the provision of advanced treatments to patients nearing the end of their lives. It offers common-sense advice like engaging in frank and open communication with a patient and their family as soon as a terminal diagnosis is made and considering a time limited trial of intensive care to establish the presence of any reversibility in the patient’s illness.  While discussing conflict resolution in the relatively small proportion of situations when patients or their families disagree with the recommendation of a doctor not to provide CPR the policy states: “While the conflict resolution process is underway, if an event requiring CPR occurs, physicians must provide CPR. In so doing, physicians must act in good faith and use their professional judgment to determine how long to continue providing CPR.”  It is 4 words in that statement “Physicians must provide CPR” that has intensivists, palliative care physicians and ethicists in Ontario feeling uneasy.

Before examining the CPSO policy and its potential ramifications elsewhere in more detail, we should first review the history of CPR. Cardio-Pulmonary Resuscitation was first developed in the early 1960s as a means of resuscitating young patients with ventricular tachydysrhythmias. In the words of resuscitation pioneer Peter Safar, it was intended for “hearts to good to die.” These words are as true today as they were 50 years ago. No-one would doubt that, when properly performed as part of a well functioning emergency medical system, CPR can produce impressive results in this subgroup of relatively young patients who have a primary problem with their heart, and whose other organs are functioning normally. Rates of successful resuscitation of 40-60% are the norm with 20-40% of patients surviving to hospital discharge (the usual benchmark for CPR success).

Over the years, however, CPR has crept into the care of almost all patients who are coming to the end of their lives. This is despite very limited evidence of it’s effectiveness. Indeed, an early observational study of CPR, in the Journal of the American Medical Association in 1961 states that CPR should only be performed after a physician has decided that it has a reasonable chance of returning the patient to a functional existence. No-one would doubt that CPR is the appropriate treatment for a 67 year old marketing executive who has a cardiac arrest on the golf course due to a Myocardial infarct. But what about the 92 year old woman who lives in a nursing home because her dementia is so bad that she can’t feed or toilet herself, let alone recognise her family? What about the 53 year old teacher who used to climb mountains but is now bed-bound and emaciated with aggressive, metastatic pancreatic cancer and who has just slipped into a coma with his oncologist telling his family that he likely only has days to live, if not hours? Ask any doctor or nurse working in an ICU and they will recount story after story of being asked to perform CPR on these patients and many others like them. Continue asking and some will tell you about nightmares, flashbacks, feelings of having failed their patient. Some will use the words torture and assault to describe CPR in these situations.

Some ethicists think that decision making around DNR orders is best thought of by dividing patients into 3 categories. In the first group are those in whom CPR is always an option. The patient who has some kind of abnormality with their heart, but no significant disease in other organs, and who has a sudden, reversible collapse, Many, if not most, patients in this group will walk out of the hospital and enjoy a quality of life the same as, or similar to that which they enjoyed before having a cardiac arrest. The second group is the largest. These are patients whose heart has stopped as a consequence of a chronic, progressive and ultimately terminal illness. These are people with metastatic cancer, chronic obstructive pulmonary disease (COPD), congestive heart failure and dementia. These are patients in whom most physicians would recommend against CPR but would likely perform it if a patient or their family insisted. The recommendation against CPR comes from evidence showing dismal outcomes, with only a couple of percent of patients leaving hospital – many of those to long term care facility and around half of the survivors dying within a year.

The final group of patients is relatively small but lie at the crux of the controversies that sometimes arise around unilateral DNR orders by physicians. These are patients who are clearly dying and in whom CPR will likely achieve nothing except changing the manner in which the patient dies. These are patients like Fred with chronic illnesses like those above that are so advanced that they are bed-bound and comatose; but also patients in ICU who are critically Ill with infections or injuries that are unable to be controlled with even the best medical care available. These patients are typically on such high levels of support that deterioration portends imminent death. In these patients a frank and tactful discussion between the physician and the family is required. The physician must point out the gravity of the situation, the imminence of death and the fact that CPR will not change this. In the small number of cases where families disagree with this assessment, a second opinion should be offered, and perhaps an ethics committee convened. But if a patient suffers from a cardiac arrest while this process is underway, no physician should be compelled to provide a treatment that will not help their patient.

The public at large already have very unrealistic views about the abilities and limitations of modern medicine. Most get their knowledge of critical illness from TV dramas where death is uncommon. An article in the New England Journal of Medicine in 1997 compared survival from CPR in popular medical dramas at the time with actual survival data obtained from data registries. Survival on TV shows was 67% compared with 30% for registry data. In addition all bar one of the 40 patients who survived their cardiac arrest on TV had perfect neurological function with no disability, whereas a high proportion of real world cardiac arrest survivors end up with some kind of disability.

Because of the large number of deaths and devastating injuries seen in the ICU, intensivists have a deep understanding of the principles of biomedical ethics and fully understand the current desire to increase patient autonomy. But there are 4 pillars of medical ethics. In addition to autonomy there is beneficence, non-maleficence and distributive justice. Encouraging physicians to perform CPR that isn’t indicated may preserve patient autonomy, but it isn’t beneficial, it will cause harm and it potentially affects other patients by filling ICUs with patients who have no hope of survival. Some might argue that not offering CPR as an option harks back to medical paternalism of days gone by. I disagree, I feel that offering a treatment that won’t work to a frightened and overwhelmed family offers nothing but false hope and thus not suggesting CPR in futile situations is entirely in keeping with the modern patient centred practice of medicine.

The medical profession as a whole has to accept some of the blame for the current state of affairs too. The oncologists, pulmonologists and cardiologists looking after patients with chronic, incurable illnesses are often reluctant to discuss end of life issues with their patients, worried that they will lose hope – despite evidence to the contrary showing that early frank and honest conversations and involvement of palliative care teams leads to less symptoms, greater quality of life and may even prolong life. Too often the first time that a patient or his family is told that their condition is terminal is by an intensivist during a deterioration. They rightly ask “who I this stranger and why is he telling me something different to the physician I have known for years?” Disagreements over end of life care become almost inevitable.

The first line of the Hippocratic Oath, sworn by physicians as they graduate from medical school, is “Primum non nocere.” First do no harm. Cardio-Pulmonary Resuscitation is harmful. Anyone who argues otherwise hasn’t seen it being performed. Ribs are broken, muscles spasm violently as thousands of volts of electricity pass through them, a thick breathing tube is forced into the windpipe without anaesthetic, power drills burr into bones to gain access to the bone marrow for administration of fluids and medications. As a society we have allowed this barbaric treatment to continue for half a century because of its potential to save those hearts too good to die. Like all treatments in medicine, harms are balanced against benefits and if the harms outweigh the benefits, the treatment is not offered. Requiring CPR to be performed, against the better judgement of doctors and nurses who do it every day, makes no sense. Requiring physicians to perform CPR in futile situations will not save a single life. Instead it will discourage physicians from having conversations that are already hard to have and will remove loving family and friends from the bedside of a dying patient, replacing them with a hastily assembled team of strangers who will perform a treatment that has become nothing more than a futile ritual. If those 4 words “Physicians must perform CPR” from the CPSO policy spread into policy documents of medical regulators elsewhere in the world, end of life care for dying patients will suffer and dedicated physicians and nurses with years of experience will leave the ICU in their droves and seek a calling elsewhere, rather than perform a futile intervention on their most vulnerable patients.



I saw this video a while back and have been thinking about it again recently. Every day we wander the corridors of the hospital and as we go on our way our eyes meet with those of patients and visitors. And every now then you can tell from their eyes that they’re possibly having the worst day of their life so far. All that we can do of course is smile and move on. Perhaps even pretend we haven’t seen them. This video (despite being blatant advertising for the Cleveland Clinic) give a hint as to what’s going on behind those eyes that we see every day.

I thought it was quite moving. Apparently it’s shown to all staff when they start at the hospital, doctors included to encourage to think about empathy.

I can’t remember what social media source led me to the video, so sincere apologies to whoever directed me to it and now isn’t being referenced!



Here are the slides and references for the talk I’m giving on Acute Liver Failure (ALF) at the Bedside Critical Care meeting in Cairns, QLD on Thursday 26th September 2013.

Lee WM, Stravitz RT, Larson AM. Introduction to the revised American Association for the Study of Liver Diseases position paper on acute liver failure 2011. Hepatology. 2012 Feb. 23;55(3):965–967.
The most up-to-date guidelines from the American Association for the Study of Liver Disease. Freely available here.

Patton H, Misel M, Gish RG. Acute liver failure in adults: an evidence-based management protocol for clinicians. Gastroenterol Hepatol (N Y). 2012 Mar.;8(3):161–212.
Another recent and easy to read review of ICU management of ALF. Also freely available here.

Bernal W, Auzinger G, Dhawan A, Wendon J. Acute liver failure. The Lancet. 2010 Jul. 17;376(9736):190–201.
Slightly older but still pretty good review from the Lancet.

Drolz A, Jäger B, Wewalka M, Saxa R, Horvatits T, Roedl K, et al. Clinical impact of arterial ammonia levels in ICU patients with different liver diseases. Intensive Care Med. 2013 May 1;39(7):1227–1237.

Holena DN, Tolstoy NS, Mills AM, Fox AD, Levine JM. Therapeutic Hypothermia for Treatment of Intractable Intracranial Hypertension After Liver Transplantation. American Journal of Critical Care. 2011 Dec. 31;21(1):72–75.

Cholongitas E, Theocharidou E, Vasianopoulou P, Betrosian A, Shaw S, Patch D, et al. Comparison of the sequential organ failure assessment score with the King’s College Hospital criteria and the model for end-stage liver disease score for the prognosis of acetaminophen-induced acute liver failure. Liver Transpl. 2012 Mar. 29;18(4):405–412.

Harbrecht BG. Predicting outcome in patients with acute liver failure. Critical Care Medicine. 2012 May;40(5):1666–1667.

Faybik P, Krenn C-G. Extracorporeal liver support. Current Opinion in Critical Care. 2013 Apr.;19(2):149–153.

Induction agent poll – Results

A while back I asked you what drugs you use to induce anaesthesia in critically ill patients. Here are the results. You can see that about 1/4 of you are happy to stick with propofol as long as the patient isn’t hypotensive. In the hypotensive patient there is a big swing to ketamine, most often on it’s own.

My practice is to use ketamine and fentanyl together as the induction agent, with rocuronium as the muscle relaxant. For post intubation sedation I tend to use propofol and fentanyl mainly for institutional reasons. However I always use an opioid heavy cocktail and if hypotension is an issue I just use fentanyl – or add a homeopathic amount of propofol to prevent people from thinking that I’ve forgotten it and adding in a stupid amount.

What Drug(s) would you typically use for RSI in a critically ill patient who isn’t hypotensive?
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What drug(s) would you use for RSI in a critically ill patient who is hypotensive?
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What Drug(s) would you typically use for RSI in a critically ill patient who isn’t hypotensive?
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Is propofol really that bad?

I recently had a Facebook conversation with a colleague of mine, emergency medicine registrar Matthew Oliver about post intubation sedation with propofol and I thought it was was worth sharing the main points of it.  Mat brought to my attention a side-splitting rant by critical care superhero Cliff Reid on ercast about propofol use in the resus room, and it got me thinking about my own practice regarding inducation and sedation in the critically ill.

Before I put a post together though,  I thought I’d conduct a little survey of the online critical care community to see what people are doing around the world regarding induction of anaesthesia and maintenance of sedation in critically ill patients.  So please answer the survey questions and I’ll use the results in my upcoming post on sedation in the critically ill.  The polls are only referring to sedatives.  I’m assuming that you’re using a muscle relaxant as I think that intubation facilitated by sedation borders on negligence (a post for another day perhaps).

After you’ve answered the poll, you should check out this link to the BMJ from 1944. That’s right 1944.  It gives an amazing insight into care of critically ill trauma patients during WWII.  Most of the patients died, and the authors recommended anaesthesia with cyclopropane, which I’m not sure I would.  But they do make this very insightful comment right at the end of the paper:

“The chief factors  in anaesthetizing shocked  patients seem, therefore, to be, first,  the use  of a  minimal- amount of anaesthetic – and it is often surprising  how little these patients require; secondly, the choice of an anaesthetic which stimulates rather than  depresses the cardiovascular system; and, thirdly, an  adequate amount of oxygen.”

Anyway, on to the poll. Please leave any comments below if there’s a drug that you think is missing!

Crisis. Check.

I’m a big fan of checklists, and I think they’re seriously under-utilised in medicine.  Anyone who’s had anything to do with aviation knows that pilots rely on checklists to ensure that important steps aren’t missed, regardless of whether the procedure being performed is routine (take-off, landing) or extra-ordinary  (smoke in the cockpit, double engine failure).  While anaesthetists and. as a result, surgeons have increasingly adopted checklists for routine aspects of surgery (The WHO surgical safety checklist for example) but there still seems to be a reluctance to use checklists in a crisis.  I’ve heard people say “there isn’t time for a checklist” or, even worse “I’m a specialist, I don’t need a checklist to manage a crisis.”

In my humble opinion, if a pilot has time to use a checklist while plummeting towards the ground, a doctor has time to use a checklist while dealing with a crisis that he or she may not have dealt with for years, if ever.  The main image of this post is from the Apollo 13 mission, where a series of checklists saved 3 astronaut’s lives in a situation of extreme pressure and very high cognitive loads.

Atul Gawande (@Atul_Gawande)is an American surgeon who should really need no introduction.  He is the Author of many books and essays commenting on organisation aspects of medicine, and my favourite would have to be “The Checklist Manifesto” which should be compulsory reading for all staff in critical care.

He and his team from Harvard published a neat little study today in the NEJM (Alas, subscription required) comparing performance of an operating room team in simulated crisis scenarios with and without a checklist.  The results speak for themselves.  Those teams using the checklist missed 6% of steps in the management of a complex emergency like massive haemorrhage while those without the checklist missed 23% of steps.  The full checklists are available in the supplementary appendix of the article.  As all good checklists should be, they’re simple, colourful and to the point.  Gawande’s team also have a website, projectcheck.org where, in the spirit of FOAMed, they’re making checklists freely available and providing a forum for others to upload checklists that they have developed.

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Of course there is already an example of checklist use in a high pressure scenario that is becoming increasingly ubiquitous – thePrehospital RSI checklist that is used by HEMS the world over.  It is a simple method of ensuring that not only the right equipment is available for a common yet complex and risky procedure, but that clinicians are cognitively prepared to use rescue equipment such as the surgical airway kit.  Many HEMS physicians are now bringing the RSI checklist into their in-hospital practice, and it seems that it is being well received. Toby Fogg (@TobyF) and his colleagues from Royal North Shore Hospital ED in Sydney have developed an ED airway registry and have a great website on which the have a copy of their in-hospital RSI checklist.   Of course clinicians in prehospital care have, in a way, been using checklists for years.  Most EMS systems issue pocket sized guides to their clinical guidelines and it is common practice for paramedics and EMTs to pull them out to refer to while treating a patient.  These guides, while not checklists, are still useful aide memoirs.

Another criticism of the checklist is that if there is only one provider present (rare in-hospital, but not uncommon prehospital) then the checklist will either take too long, or be performed poorly, with steps being skipped while the clinician’s attention is divided.  Again, we can look to aviation for a potential solution.  Many single pilot aircraft have an automated checklist system which reads the steps out in a voice that sounds alarmingly like Stephen Hawking.  Now how can medicine not be improved if Stephen Hawking is your wingman?  A smartphone or tablet based automated crisis checklist could be the answer for solo providers.

Hopefully in the near future the “doctor knows best” attitude in medicine will be a thing of the past and teams caring for critically ill patients will be using checklists all the time to guide and prompt their management of both common and uncommon crises.  I’ve been working on my own set of ICU checklists for a while and I’d be keen to hear from people who have used checklists like the prehospital RSI checklist or who have developed their own crisis checklists.

Here’s the abstract of the NEJM study.
Simulation-Based Trial of Surgical-Crisis Checklists
Alexander F. Arriaga, M.D., M.P.H., Sc.D., Angela M. Bader, M.D., M.P.H., Judith M. Wong, M.D., M.P.H., Stuart R. Lipsitz, Sc.D., William R. Berry, M.D., M.P.H., M.P.A., John E. Ziewacz, M.D., M.P.H., David L. Hepner, M.D., Daniel J. Boorman, B.S., Charles N. Pozner, M.D., Douglas S. Smink, M.D., M.P.H., and Atul A. Gawande, M.D., M.P.H.
N Engl J Med 2013; 368:246-253 January 17, 2013 DOI: 10.1056/NEJMsa1204720

Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events.

Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists.

A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P<0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P<0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used.

In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.)

A Fridge too Far?

How apt that this morning I watched one of my favourite episodes of “The Simpsons,” “King-Size Homer” from series 7, in which Homer gains 60 Lbs in order to reach 300 Lbs, allowing him to work from home on a disability scheme.  As always, The Simpsons provide a very accurate commentary on modern society, in this case the obesity epidemic.  The episode contains one of my all time favourite lines from a Simpsons episode; when Homer is refused entry to the movie “Honk if you’re Horny” on account of the cinema seats being inadequate for his girth, a fellow movie-goer jibes “Hey, fatty. I’ve got a movie for ya – A fridge too far!”

Anyway, what does this have to do with intensive care.  Well an early release article appeared the other day in “Critical Care” that caught my eye.  Abhyankar et al retrospectively reviewed a large ICU database from a single hospital in Boston, MA.  Sounds dodgy, but the database had 16,812 patients covering a 7 year period from 2001-2008.  Some of the over 25,000 patients in the MIMIC database were excluded (children, no weight available) leaving 16,812 for analysis.

The authors compared 30 day and 1 year all cause mortality with BMI, using the standard WHO categories of underweight (<18.5), normal weight (18.6-25), Overweight (25-30) and Obese (>30).  They controlled for SAPS score, comorbidities, gender, insurance status, and ethnicity.  Height wasn’t available for 25% of patients, so they had a height allocated based on their other demographic factors.  The final analysis was conducted with and without these patients.

The results were pretty impressive.  OR for mortality in overweight patients was 0.81 at 30 days and 0.68 at one year.  Even more impressive were the results for obese patients, OR for death 0.74 at 30 days, 0.57 at one year.  So if you’re obese you’re almost half as likely to die following an ICU admission than someone who is normal weight.  Of note, the survival advantage disappears for the very obese (BMO >40).  Results were all significant.

I think that the authors did a pretty good job controlling for potential confounders like diabetes, obesity related cancers, age, SAPS score, etc.  The results were also similar when the 25% with guessed heights were removed.

So what’s going on?  The authors have a couple of hypotheses.  One is related to immunomodulatory effects of apidocytes.  The other is a bit more simple – overweight and obese people have more nutritional reserves, giving them a survival advantage.

So perhaps one of the most effective lifesaving tools that we have in the ICU is a bucket of fried chicken…?

The paper is open access, so have a look for yourself.  Here’s the abstract if you’re short of time.


Lower short- and long-term mortality associated with overweight and obesity in a large cohort study of adult intensive care unit patients

Swapna AbhyankarKira LeishearFiona M CallaghanDina Demner-Fushman and Clement J McDonald

Critical Care 2012, 16:R235

Published: 18 December 2012

Abstract (provisional)


Two-thirds of U.S. adults are overweight or obese, which puts them at higher risk of developing chronic diseases and of death compared to normal weight individuals. However, recent studies have found that overweight and obesity by themselves may be protective in some contexts, such as hospitalization in an intensive care unit (ICU). Our objective was to determine the relationship between body mass index (BMI) and mortality 30 days and one year after ICU admission.


We performed a cohort analysis of 16,812 adult patients from MIMIC-II, a large database of ICU patients at a tertiary care hospital in Boston, Massachusetts. The data were originally collected during the course of clinical care, and we subsequently extracted our dataset independently of the study outcome.


Compared to normal weight patients, obese patients had 26% and 43% lower mortality risk at 30 days and one year after ICU admission, respectively (OR 0.74 [95% CI, 0.64-0.86] and 0.57 [95% CI, 0.49-0.67]); overweight patients had nearly 20% and 30% lower mortality risk (OR 0.81 [95% CI, 0.70-0.93] and 0.68 [95% CI, 0.59-0.79]). Severely obese patients (BMI [greater than or equal to]40 kg/m2) did not have a significant survival advantage at 30 days (OR 0.94 [95% CI, 0.74-1.20]), but did have 30% lower mortality risk at one year (OR 0.70 [95% CI, 0.54-0.90]). There was no significant difference in admission acuity or ICU and hospital length of stay across BMI categories.


Our study supports the hypothesis that patients who are overweight or obese have improved survival both 30 days and one year after ICU admission.