Temporal Dynamics and Transitions in Limitation of Life-Sustaining Treatment Across ICU Stay: A Multicenter Cohort Study

Objective: To analyze the temporal dynamics and transitions in Limitation of Life-Sustaining Treatment (LLST) classifications between ICU admission and outcome, describe associated patient profiles, and identify factors influencing these transitions in a multicenter cohort.Method: This retrospective cohort study included 13,215 adult patients admitted to ICUs across five hospitals in Curitiba, Brazil, from May 1, 2023, to December 31, 2024. Patients were daily classified into one of four LLST levels. We compared admission characteristics, severity scores (APACHE II, SOFA, Clinical Frailty Scale [CFS]), clinical course, and outcomes among groups with unchanged LLST, progression to less restrictive LLST, and progression to more restrictive LLST. Ordinal logistic regression assessed the impact of ICU admission characteristics on LLST levels at outcome, while longitudinal models evaluated daily LLST variation.Results: This multicenter retrospective study analyzed 13,215 ICU patients (2023-2024) to evaluate LLST transitions. Most patients (89.4%) maintained their initial LLST classification, while 9.8% progressed to more restrictive levels and 0.8% to less restrictive. Patients progressing to stricter LLST were older (74±14 vs. 65±17 years), had higher severity scores (APACHE II 23 vs. 11; SOFA 7 vs. 3), greater frailty (CFS 5 vs. 3), and worse outcomes (75% mortality vs. 5.8%). Key predictors included age (OR=2.3), frailty (OR=1.42 per CFS unit), and admission SOFA (OR=1.27 per unit). Half of initial LLST decisions occurred within 4 days, with escalating organ dysfunction (rising ΔSOFA) in restrictive cases. The findings underscore how patient acuity and early decisions shape LLST trajectories, highlighting opportunities to optimize end-of-life care through proactive assessment.Conclusion: LLST decisions are dynamic during ICU stays and are significantly influenced by patient age, frailty, initial severity, and admission type. A substantial proportion of patients experience progression to more restrictive LLST, which is associated with higher morbidity and mortality. Early identification of at-risk patients and proactive discussions about care goals are crucial to optimize resource allocation and improving end-of-life care quality in intensive care.研究目标：分析重症加强护理病房（Intensive Care Unit, ICU）收治患者从入院至结局期间，生命支持治疗受限（Limitation of Life-Sustaining Treatment, LLST）分级的时序动态变化与转归情况，描述相关患者的临床特征，并在多中心队列中识别影响此类转归的相关因素。 研究方法：本回顾性队列研究纳入2023年5月1日至2024年12月31日期间，巴西库里提巴市5家医院ICU收治的13215名成年患者。研究人员每日将患者划分为4种LLST分级中的1种。对比了LLST分级未发生变化、进展为限制性更低的LLST分级以及进展为限制性更高的LLST分级三组患者的入院特征、病情严重程度评分（APACHE II、SOFA、临床衰弱量表（Clinical Frailty Scale, CFS））、临床病程与结局。采用有序逻辑回归分析ICU入院特征对患者结局时LLST分级的影响，同时通过纵向模型评估患者每日LLST分级的变化情况。 研究结果：本多中心回顾性研究共纳入13215名2023-2024年的ICU患者，以评估LLST分级的转归情况。其中绝大多数患者（89.4%）维持初始LLST分级，9.8%的患者进展为限制性更高的LLST分级，仅0.8%的患者进展为限制性更低的LLST分级。进展为限制性更高LLST分级的患者年龄更大（74±14岁 vs. 65±17岁），病情严重程度评分更高（APACHE II评分23分 vs. 11分；SOFA评分7分 vs. 3分），衰弱程度更显著（CFS评分5分 vs. 3分），且结局更差（死亡率75% vs. 5.8%）。关键预测因素包括年龄（优势比OR=2.3）、衰弱程度（每升高1个CFS评分单位，OR=1.42）以及入院时SOFA评分（每升高1个评分单位，OR=1.27）。半数初始LLST分级决策于入院后4天内作出，限制性更高的LLST分级患者伴随进行性器官功能障碍（ΔSOFA评分升高）。本研究结果证实，患者的病情危重程度与早期决策决定了LLST分级的变化轨迹，同时也提示可通过主动评估优化临终关怀方案。 研究结论：ICU住院期间的LLST分级决策具有动态性，且显著受患者年龄、衰弱程度、初始病情严重程度以及入院类型的影响。相当比例的患者会进展为限制性更高的LLST分级，此类患者的并发症发生率与死亡率均更高。早期识别高危患者并主动与患者及家属沟通护理目标，对于优化重症监护中的资源配置、提升临终关怀质量至关重要。