Early decision effect of withholding and/or withdrawing life-sustaining treatment on emergency department patients’ short- and long-term outcomes: a retrospective analysis

Early decision effect of withholding and/or withdrawing life-sustaining treatment on emergency department patients’ short- and long-term outcomes: a retrospective analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Early decision effect of withholding and/or withdrawing life-sustaining treatment on emergency department patients’ short- and long-term outcomes: a retrospective analysis Joseph Sinoquet, Pradeebane Vaittinada Ayar, Prabakar Vaittinada Ayar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7357429/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background In France, a significant proportion of end-of-life (EOL) decisions occur in emergency departments (EDs), where time constraints and limited resources may hinder optimal care. Although withholding or withdrawing life-sustaining treatments (WHWD) is common in this context, the impact of timing on patient outcomes remains unclear. The study assessed how the timing of WHWD decisions influences short- and long-term outcomes among ED patients. Methods: We conducted a retrospective, observational study at Beaujon Hospital’s ED (Paris, France) between January 2020 and December 2021. We included all adult patients admitted to the observation unit with a WHWD decision. Patients were categorized into early (eWHWD) and late (lWHWD) groups based on the median time to decision. The primary endpoint was 28-day all-cause mortality. Cox regression was used for survival analysis, adjusting for age, sex, comorbidities, functional status, and severity of illness. Results: WHWD was decided in 354 patients. Patients in the eWHWD group (n = 176) were older, more functionally impaired, and had higher illness severity than those in the lWHWD group (n = 178). Early decisions occurred within a median of 2 hours versus 7 hours in the late group. Short-term mortality was significantly higher in the eWHWD group at 7 days (58% vs. 44%) and 28 days (76% vs. 65%). After adjustment, late WHWD remained independently associated with better survival at 7-days, 28-days, 90-days and 1-year. Respectively adjusted Hazard Ratios were equal to 0.71; 95% confidence interval (CI) (0.66 to 0.76), 0.73; 95% CI (0.68 to 0.78), 0.76; 95% CI (0.72 to 0.81) and 0.86; 95% CI (0.81 to 0.91). Conclusion: Early WHWD decisions reflect more severe patient conditions and are linked to poorer short and long-term outcomes. Enhancing advance care planning and integrating palliative care into ED practices may improve decision quality and align care with patient values. Emergency department end of life withholding or withdrawing life-sustaining treatments Figures Figure 1 Figure 2 Introduction Each year, approximately 650,000 deaths occur in France [ 1 ]. Despite most patients expressing a preference to die at home, 58% of these deaths still took place in hospitals, as reported by the French General inspection of Social Affairs in 2009 [ 2 ]. This was even though patients at the end of life (EOL) generally wanted to die at home [ 3 , 4 ]. This discrepancy between patients' end-of-life wishes and the reality is likely stemmed from a lack of anticipation and insufficient resources to support home care in the final days. Notably, 16% of hospital deaths occurred within the first 24 hours of admission, often in emergency departments (ED) [ 2 ]. While deaths accounted for only about 0.2% of all ED visits [ 5 ], this still represented approximately 40,000 deaths out of 20.3 million emergency visits in France in 2021. Caring for EOL patients in such settings demands significant time, material, and human resources, placing a significant emotional burden on families and healthcare teams. Importantly, between 79–87% of these deaths are preceded by decisions to withhold or withdraw life-sustaining treatments [ 6 , 7 ]. The primary mission of emergency medical services is to provide care for all individuals in emergency situations, including psychiatric emergencies, 24/7, without selection, especially in distress or life-threatening cases [ 8 ]. This mission necessitated a specific organisational structure designed to meet various constraints. However, these constraints often create an "emergency environment" which is not conducive to make withholding or withdrawing (WHWD) decisions or offering appropriate EOL care. In this fast-paced setting, the need to make and implement decisions swiftly, yet carefully, is critical. Additionally, the organisation of care heavily relies on discharge rates, which hinge on the availability of beds in other units. Frequent bed shortages contribute to overcrowding in EDs, forcing patients to wait in suboptimal conditions, with limited privacy and calm. In response to these challenges, the French Intensive Care Society and the French Society of Emergency Medicine published a joint position paper in 2018 addressing WHWD decisions in emergency care [ 9 ]. The authors acknowledged the tension between regulatory requirements and everyday realities in emergency departments. The position paper emphasised the critical importance of understanding the daily realities in EDs and respecting the patient's wishes when making WHWD decisions. It highlighted the need to review patients' medical records and assess their autonomy and cognitive state before deciding. The position paper also covered the use of deep sedation in emergency settings, stressing that the procedure should be thoroughly documented in the medical record and that physicians must ensure the patient's relatives fully understand the process. In 2020, the SFMU, in collaboration with the French Society of Palliative Care (SFAP), published a paper-based WHWD decision aid specifically designed for emergency settings [ 10 ]. However, data on the total number of WHWD implementations remained scarce. Most studies have focused on patients who died in emergency departments following a WHWD decision. However, there is limited information on patients for whom a WHWD was initiated but who survived beyond their ED stay. The aim of this study was to assess the effect of WHWD decision timing on short- and long-term outcomes of ED patients. Methods This retrospective, observational, single-centre study was conducted within the Emergency Department of Beaujon Hospital (Assistance Publique des hôpitaux de Paris (AP-HP)). The data collection period spanned from January 1, 2020, to December 31, 2021. Demographic, clinical, discharge, transfer, WHWD and death data were extracted from the Orbis® medical data processing software (healthcare software, Dedalus, Florence, Italy) or by contacting the hospital if the department does not use Orbis®. Autonomy for activities of daily living was assessed using the KNAUS classification [ 11 ] (annexe 1). This classification system describes the level of care required by older and disabled individuals, and ranges from A (completely autonomous) to D (most dependent). Patients classified as KNAUS A or B represent individuals who do not experience problems with autonomy in their daily tasks. The APACHE II score [ 12 ], the presence of legal protection guardianship, and the presence of daily nurse visits or home care were determined from the patient’s medical record. To be included, adult patients hospitalised after their ED visit must be admitted to the observation unit (OU) in association with a mention of a WHWD of the life-sustaining treatment in the ED medical record. The time between arrival and the WHWD decision was extracted from Orbis®, and the comparison of patients was done according to the median time of this decision. After WHWD, a follow-up was conducted first, for 7 and 28 days, up to the point of death or discharge from the hospital. And a follow-up was extended to 90 days and one year. The primary outcome was 28-day all-cause mortality after the WHWD decision. Ethics The work is conformed to the Declaration of Helsinki. The study was approved by the Scientific and Ethical Committee of Assistance Publique – Hopitaux de Paris (AP-HP) clinical data warehouse (IRB00011591). The database was authorised by the National Freedom and Informatics Commission (CNIL Number: 1980120). Assistance Publique – Hopitaux de Paris (AP-HP) clinical data warehouse initiative ensures patients’ information and consent regarding the approved studies through a transparency portal following European Regulation on data protection and authorisation (number 1980120) from the National Freedom and Informatics Commission. The need for informed consent was waived by the Scientific and Ethical Committee of Assistance Publique – Hopitaux de Paris (AP-HP) clinical data warehouse, because of the retrospective nature of the study. The study was retrospectively registered at ClinicalTrials.gov on 4 August 2025 (NCT07115719). Statistical Analysis Continuous variables are expressed as median [interquartile range (IQR)]. Categorical variables are presented as a number (percentage). The normality of all variables was checked using the Shapiro-Wilk test. Group characteristics were compared using the t-test for normally distributed continuous variables, the Mann-Whitney test for non-normally distributed continuous variables, or the χ² test for categorical variables. Hazard ratio (HR) and 95% confidence interval (95% CI) for 7, 28, 90-day and 1-year all-cause mortality were calculated using a Cox proportional hazards regression model. Variables with a p < 0.10 on univariate analysis were entered into the Cox regression model to describe how the factors jointly impact survival. We also kept comorbidity as a key confounder. The optimal model selection involved finding the best compromise between the number of factors to keep and the accuracy of the Cox regression analysis. The model was adjusted with age, sexe, dementia, active cancer, KNAUS scale, APACHE II score and home care. The proportional hazards assumption was checked using statistical tests based on the scaled Schoenfeld residuals. Analyses were performed using R® software (R Development Core Team, R Foundation for Statistical Computing, Vienna, Austria). A two-sided p-value of less than 0.05 was considered statistically significant. Sample Size The estimated population is 140 patients, considering the 0.2% mortality rate in the emergency department, and the 35,000 annual visits at the Beaujon emergency department over two years. Results Between January 1, 2020, and December 31, 2021, there were 64,239 emergency department (ED) visits at Beaujon Hospital. Among these, 7,707 patients were hospitalised, and 354 cases involving a decision to limit or withdraw life-sustaining treatments (WHWD) were included in the study (Fig. 1 ). The median age of included patients was 83 years (IQR 72–90), and 53% were women (Table 1 ). The median time between ED arrival and WHWD decision was 242 minutes (IQR 119–426). The median time to decision was approximately 2 hours in the eWHWD (early WHWD) group and 7 hours in the lWHWD (late WHWD) group. Sixty-one per cent of patients lived at home, while 39% were institutionalised. According to the Knaus classification, 7% of patients were class A or B, 46% class C, and 46% class D. Patients classified as Knaus D were more frequent in the eWHWD group (56% vs. 37%; p = 0.0005), while class C was more common in the lWHWD group (56% vs. 35%; p < 0.001). Regarding medical history, dementia was present in 50% of patients, heart disease in 40%, and active cancer in 26%. Dementia was more prevalent in the eWHWD group (57% vs. 44%; p = 0.014), while active cancers were more frequent in the lWHWD group (19% vs. 10%; p = 0.026). Seventy-seven per cent of patients were transported by ambulance, and 19% by Emergency medical service (EMS). Medicalised transport was more common in the eWHWD group (29% vs. 10%; p < 0.001). The most frequent reasons for ED admission were respiratory (61%) and neurological (46%). Patients in the eWHWD group more often presented with respiratory (56% vs. 40%; p = 0.004), circulatory (39% vs. 23%; p = 0.001), and neurological failures (31% vs. 15%; p = 0.0003). Clinically, early WHWD patients had lower mean arterial pressure and Glasgow scores and required more oxygen. The median APACHE II score for all patients was 16. The score was significantly higher in eWHWD patients (median 18 vs. 14.5; p < 0.001). Table 1 Baseline characteristics Variable Available data N (%) Total EWHWD (N = 176) LWHWD (N = 178) P -value Age Median (Q1 - Q3) 354 (100) 83 (72–90) 83 (75–92) 81 (70–89) 0.074 Time between Arrival and WHWD decision 354 (100) 242 (119–426) 117 (51–181) 414 (311–696) < 0.001 Sexe Men 354 (100) 165 (47) 72 (41) 93 (52) 0.033 Women 189 (53) 104 (59) 85 (48) Living place Home 354 (100) 216 (61) 101 (57) 114 (64) 0.20 Nursing Home 138 (39) 75 (43) 63 (34) 0.066 Social isolation 354 (100) 55 (16) 27 (15) 28 (16) 0.90 Legal protection guardianship 354 (100) 59 (17) 28 (16) 31 (17) 0.70 Home care 352 (99) 250 (71) 141 (81) 109 (62) < 0.001 Knaus scale A 347 (98) 1 (0) 1(1) 0 (0) 0.50 B 26 (7) 14 (8) 12 (7) 0.65 C 159 (46) 61 (35) 98 (56) < 0.001 D 161 (46) 96 (56) 65 (37) < 0.001 Medical history Psychiatric disorders 354 (100) 19 (5) 8 (5) 11 (6) 0.50 Dementia 178 (50) 100 (57) 78 (44) 0.014 Neurodegenerative disorders 51 (14) 23 (13) 28 (16) 0.48 Stroke 50 (14) 29 (16) 21 (12) 0.21 Heart disease 140 (40) 75 (43) 65 (37) 0.22 Respiratory disease 57 (16) 30 (17) 27 (15) 0.63 Chronicle kidney disease 44 (12) 26 (15) 18 (10) 0.18 Liver disease 11 (3) 4 (2) 7 (4) 0.37 Diabetes 89 (25) 46 (26) 43 (24) 0.67 Immunodefiency 3 (1) 1 (1) 2 (1) 1.00 Active cancer 93 (26) 38 (22) 55 (31) 0.047 ED presentation Ambulance 354 (100) 282 (80) 124 (70) 158(89) < 0.001 EMS 69 (19) 51 (29) 18 (10) < 0.001 Self-presented 3 (1) 1 (1) 2 (1) 1.00 Hospitalisation during last 6 months 354 (100) 203 (57) 103 (59) 100 (56) 0.66 Main complaint Dyspnea 354 (100) 217 (61) 118 (67) 99 (56) 0.027 Hypotension 94 (27) 66 (38) 28 (16) < 0.001 Neurologic 164 (46) 103 (59) 61 (34) < 0.001 Abdomen 61 (17) 18 (10) 43 (24) < 0.001 Metabolic 23 (6) 11 (6) 12 (7) 0.85 Traumatology 20 (6) 10 (6) 10 (6) 0.98 Haemorrhage 27 (8) 9 (5) 18 (10) 0.079 Acute pain 40 (11) 13 (7) 27 (15) 0.021 Infection 187 (53) 95 (54) 92 (52) 0.67 Toxicology 5 (1) 2 (2) 3 (2) 0.62 Asthenia 97 (27) 31 (18) 66 (37) < 0.001 Multiple 310 (88) 153 (87) 157 (88) 0.72 Clinical parameters Temperature 350 (99) 36.6 (36.1–37.2) 36.6 (36–37.3) 36.6 (36.2–37.2) 0.83 Mean blood pressure 83.5 (64–100) 79 (60–97) 85.5 (70–103) 0.016 Heart rate (bpm) 94 (80–108) 98 (81.5–110) 93 (78–107) 0.18 Glasgow coma scale 14 (9–15) 12 (7–14) 14 (13–15) < 0.001 Oxygen need (L/min) 4 (0–9) 5 (0–12) 3 (0–6) 0.002 Laboratory tests PaO2 (mmHg) 162 (46) 82 (67–119) 91 (70–130) 77 (66–108) 0.002 pH 162 (46) 7.36 (7.28–7.43) 7.34 (7.26–7.41) 7.37 (7.3–7.44) 0.094 Sodium (mmol/L) 334 (94) 138 (134–142) 139 (134–142) 138 (134–142) 0.32 Potassium (mmol/L) 334 (94) 4.4 (3.9–5.2) 4.5 (3.9–5.25) 4.4 (3.9–5) 0.81 Creatinine (µmol/L) 334 (94) 115 (72–199) 131 (74–209) 105.5 (71–176) 0.74 Leucocytes (/mm 3) 330 (93) 12.6 (8.6–18.5) 13.8 (9.3–20) 11.9 (8.3–17.6) 0.079 Haemoglobin (g/dl) 330 (93) 11.7 (9.8–13.3) 11.9 (10.1–13.4) 11.7 (9.7–13.2) 0.24 APACHE II Median (Q1 - Q3) 334 (94) 16 (13–21) 18 (14.5–22.5) 14.5 (12–18) < 0.001 APACHE I: Acute Physiologic Assessment and Chronic Health Evaluation Scoring System II EMS: emergency medical service GIR: groupe iso-ressource WHWD: Withholding/Withdrawing The principle of collegiality in WHWD decisions was followed in 84% of cases, with no difference between groups (Table 2). Intensivists were the most frequent medical partners (45%). Most patients (77%) were deemed unable to express their preferences due to cognitive disorders or altered consciousness. The eWHWD group had a lower proportion of patients considered capable of expressing their wishes (14% vs. 33%; p < 0.001), but overall patient involvement was low (7%) and not significantly different between groups. Advance directives were recorded in only 3% of cases, and a trusted person was identified in 13%. There was no significant difference between groups regarding advance directive presence, identification of a trusted person, or physician involvement. The main reasons cited for WHWD were disproportionate care (86%), poor anticipated quality of life (44%), and terminal prognosis (43%). Poor quality of life was oftentimes cited in eWHWD decisions (50% vs. 37%; p = 0.014). Supportive care, including oxygen therapy and fluid resuscitation, was more frequently administered in the eWHWD group. These therapies and non-invasive ventilation were also more often limited in that group. WHWD involved limitation of treatment in 88% of cases and withdrawal in 12%. Only 7% of patients were evaluated by the hospital palliative care team, with no significant difference between groups. Pain assessment was recorded in 81% of patients, with no group differences. Comfort care measures included sedation with Midazolam in 21% of patients and analgesia with Morphine in 29%. Both were used more frequently in the eWHWD group: Midazolam (27% vs. 15%; p = 0.0009) and Morphine (38% vs. 21%; p = 0.008). Table 2 End of life decision process and treatment Variable Available data N (%) Total EWHWD (N = 176) LWHWD (N = 178) P -value Collegial WHWD process 354 (100) 297 (84) 151 (86) 146 (82) 0.33 Participant None 354 (100) 54 (15) 23 (13) 31 (17) 0.26 Many 46 (13) 25 (14) 21 (12) 0.50 Intensivist 160 (45) 80 (45) 80 (45) 0.92 Gerontologist 18 (5) 12 (7) 6 (3) 0.14 Oncologist 25 (7) 8 (5) 17 (10) 0.066 Surgeon 13 (4) 4 (2) 9 (5) 0.16 Orther ED physician 29 (8) 21 (12) 8 (4) 0.011 Other 12 (3) 4 (2) 8 (4) 0.25 Patient able to decide 354 (100) 83 (23) 25 (14) 58 (33) < 0.001 Criteria for assessing patient incapacity to make a decision Neurocognitive disorders 354 (100) 85 (24) 31 (18) 30 (17) 0.85 Confusion ou coma 61 (17) 48 (27) 41 (23) 0.36 Both 119 (34) 69 (39) 50 (28) 0.027 Patient directly involved in making decisions 354 (100) 25 (7) 31 (18) 30 (17) 0.85 Advanced health care directives 354 (100) 12 (3) 48 (27) 41 (23) 0.36 Known surrogate 354 (100) 45 (13) 69 (39) 50 (28) 0.027 Involvement of the primary care physician in decision-making 354 (100) 7 (2) 31 (18) 30 (17) 0.85 Involvement of the specialist in decision-making 354 (100) 55 (16) 48 (27) 41 (23) 0.36 Involvement of the paramedical team in decision-making 354 (100) 9 (3) 69 (39) 50 (28) 0.027 Assessment of autonomy and quality of life 354 (100) 332 (94) 31 (18) 30 (17) 0.85 Reason of WHWD Predictable short-term mortality linked to an incurable chronic disease 354 (100) 151 (43) 66 (38) 85 (48) 0.051 Irreversibility of the acute condition. 94 (27) 43 (24) 51 (29) 0.37 Current or future quality of life 154 (44) 88 (50) 66 (37) 0.014 Care considered too invasive given the risk-benefit ratio 303 (86) 148 (84) 155 (87) 0.42 Family request 17 (5) 12 (7) 5 (3) 0.42 none 44 (12) 25 (14) 19 (11) 0.31 Life-sustaining treatments initiated before WHWD CPR 354 (100) 9 (3) 4 (2) 5 (3) 1.00 Orotracheal intubation and mechanical ventilation 4 (1) 2 (1) 2 (1) 1.00 Non-invasive ventilation 28 (8) 11 (6) 17 (10) 0.25 High-flow oxygen therapy 115 (32) 66 (38) 49 (28) 0.045 Catecholamines infusion 4 (1) 2 (1) 2 (1) 1.00 Fluid resuscitation 105 (30) 62 (35) 43 (24) 0.023 Renal replacement therapy 0 (0) 0 (0) 0 (0) NA Emergency surgery or endoscopy 4 (1) 2 (1) 2 (1) 1.00 Total 201 (57) 112 (64) 89 (50) 0.010 Other treatments initiated before WHWD Low-flow oxygen therapy 354 (100) 241 (68) 125 (71) 116 (65) 0.24 Peripheral venous catheter 347 (98) 169 (96) 178 (100) 0.007 Venous blood tests 333 (96) 155 (88) 178 (100) < 0.0001 Arterial blood tests 166 (47) 75 (43) 91 (51) 0.11 Subcutaneous infusion 4 (1) 4 (2) 0 (0) 0.060 Antibiotherapy 229 (65) 117 (66) 112 (63) 0.48 Anticoagulation 104 (29) 42 (24) 62 (35) 0.024 Transfusion 24 (7) 7 (4) 17 (10) 0.088 Life-sustaining treatments stopped or not initiated after WHWD CPR 354 (100) 354 (100) 176 (100) 178 (100) 1.00 Orotracheal intubation and mechanical ventilation 353 (99) 176 (100) 177 (99) 1.00 Non-invasive ventilation 161 (45) 94 (53) 67 (38) 0.003 High-flow oxygen therapy 49 (14) 33 (19) 16 (9) 0.008 Catecholamines infusion 327 (92) 167 (95) 160 (90) 0.076 Fluid resuscitation 45 (13) 29 (16) 16 (9) 0.034 Renal replacement therapy 332 (94) 167 (95) 165 (93) 0.39 Emergency surgery or endoscopy 269 (76) 138 (78) 131 (74) 0.29 Other treatments stopped or not initiated after WHWD Low-flow oxygen therapy 354 (100) 13 (4) 9 (5) 4 (2) 0.15 Peripheral venous catheter 11 (3) 5 (3) 6 (3) 0.77 Venous blood tests 43 (12) 27 (15) 16 (9) 0.067 Arterial blood tests 63 (18) 35 (20) 28 (16) 0.31 Subcutaneous infusion 9 (3) 6 (3) 3 (2) 0.34 Antibiotherapy 18 (5) 11 (6) 7 (4) 0.32 Anticoagulation 31 (9) 21 (12) 10 (6) 0.036 Transfusion 51 (14) 31 (18) 20 (11) 0.088 Withdrawal of life-sustaining treatments 354 (100) 44 (12) 26 (15) 18 (10) 0.18 Patient known by the palliative care 354 (100) 27 (8) 12 (7) 15 (8) 0.57 Patient assessed by the palliative care 354 (100) 25 (7) 12 (7) 13 (7) 0.86 Assessment of physical or mental pain 354 (100) 287 (81) 142 (81) 145 (81) 0.85 Palliative care initiated Midazolam 354 (100) 74 (21) 47 (27) 27 (15) 0.008 Morphin 104 (29) 66 (38) 38 (21) 0.0009 Scopolamin 29 (8) 19 (11) 10 (6) 0.078 CPR: Cardiopulmonary Resuscitation; ED: Emergency department; WHWD: Withholding/Withdrawing Data are presented as median (interquartile range) for continuous data and as number (percentage) for categorical data. The P-value to the right represent the test for trend determined by either Wilcoxon rank-sum (continuous data) or chisquare [categorical data] Regarding outcomes (Table 3), 31% of patients died in the ED, 32% died in downstream units, and 35% were discharged alive. ED mortality was higher in the eWHWD group (39% vs. 22%; p = 0.0005), while downstream unit mortality was higher in the lWHWD group (38% vs. 27%; p = 0.030). Discharge rates were similar between groups. The mortality of the whole population at 7, 28, 90-day and 1-year was 51%, 70%, 82% and 90% respectively. At 7 days, 58% of eWHWD patients had died, compared to 44% in the late group (p = 0.008). Seventy-six per cent of the overall eWHWD patients died within 28 days, compared to 65% in the lWHWD group (p = 0.022). There was no significant difference at 90 days or one year. Table 3 outcomes Variable Available data N (%) Total EWHWD (N = 176) LWHWD (N = 178) P -value ED mortality 353 (99) 108 (31) 69 (39) 39 (22) < 0.001 Post-ED disposition Acute geriatric ward 245 (69) 119 (49) 57 (53) 62 (45) 0.19 Internal medicine ward 33 (13) 14 (13) 19 (14) 0.88 Home / Nursing Home 33 (13) 18 (17) 15 (11) 0.18 Palliative care 14 (6) 4 (4) 10 (7) 0.24 Other 24 (10) 6 (6) 18 (13) 0.052 Mortality in admission ward 349 (98) 114 (33) 48 (27) 66 (38) 0.030 Post ward disposition Home / Nursing Home 101 (28) 79 (79) 20 (47) 24 (41) 0.61 Palliative care 17 (17) 5 (12) 12 (21) 0.21 Other 4 (4) 0 (0) 4 (7) 0.13 Discharged Alive 347 (98) 124 (32) 56 (32) 68 (40) 0.12 7–days mortality 347 (98) 177 (51) 100 (58) 77 (44) 0.008 28–days mortality 344 (97) 242 (70) 130 (76) 112 (65) 0.022 90–days mortality 329 (93) 270 (82) 143 (86) 127 (78) 0.052 1–year mortality 326 (92) 295 (90) 152 (92) 143 (89) 0.31 ED: Emergency department; WHWD: Withholding/Withdrawing Data are presented as median (interquartile range) for continuous data and as number (percentage) for categorical data. The P-value to the right represent the test for trend determined by either Wilcoxon rank-sum (continuous data) or chisquare [categorical data] The relationship between the timing of a WHWD decision and survival favoured the late group decision regarding the short-term prognostic (Fig. 2 ). The unadjusted hazard ratio (HR) was lower in lWHWD for 7- and 28-day survival, respectively HR = 0.61; 95% CI (0.45 to 0.82) and 0.66; 95% CI (0.51 to 0.85). The adjusted HR for short-term prognostic stay in favour of late decision group. For long-term prognostic (90 days and 1 year survival), there was no difference between the 2 groups according to the unadjusted HR (Fig. 2 ). But after adjustment with the age, sex, dementia, active cancer, KNAUS scale, APACHE II score, and home care, the HR at 90-day and one year was significantly in favour of lWHWD group, respectively adjusted HR = 0.76; 95% CI (0.72 to 0.81) and 0.86; 95% CI (0.81 to 0.91). Discussion This study investigated the outcomes of early versus late decisions to limit or withdraw life-sustaining treatments (WHWD) in emergency department (ED) patients. Our findings reveal significant differences in patient characteristics, care pathways, and short-term mortality between early WHWD (eWHWD) and late WHWD (lWHWD) groups, underscoring the complexity of end-of-life (EOL) decision-making in the emergency setting. Timing and Mortality Outcomes The median delay to WHWD decision was significantly shorter in the eWHWD group (approximately 2 hours) compared to the lWHWD group (7 hours). This timing was closely associated with early mortality. Specifically, eWHWD patients had significantly higher mortality at 7 and 28 days. While this may initially suggest a negative impact of earlier decisions, it likely reflects the severity of illness and the acute context in which these decisions were made, rather than premature decision-making. These results align with findings by Hua et al. [ 16 , 17 ] who reported higher early mortality among patients with rapidly made WHWD decisions in intensive care units. Notably, after adjusting for confounders, late WHWD remained independently associated with improved survival even at 90 days and 1 year, suggesting that, when possible, a delayed and more comprehensive decision-making process might be beneficial. However, it is critical to note that the latter group may benefit from more complete diagnostic evaluations, discussions with families, and collegial processes, all of which may improve the quality of decision-making rather than merely delay it [ 18 , 19 ]. Decision-Making Practices and Ethical Considerations Despite legal and professional guidelines emphasising patient involvement, our study revealed a low patient involvement rate (7%) in WHWD decisions, with only 3% having documented advance directives. These findings underscore persistent challenges in anticipatory EOL planning and communication, especially in emergency settings where many patients arrive with impaired consciousness or no clear medical history [ 20 ]. The low uptake of advance directives is also echoed in broader French studies[ 21 ] and may reflect societal, cultural, or systemic barriers to proactive care planning. Moreover, while the collegiality principle was applied in 84% of cases consistent with French legal requirements consultation with palliative care teams remained rare (7%). This underutilization has been previously noted [ 22 ], and it may stem from the limited availability of palliative care professionals in EDs, especially outside regular working hours. The higher use of comfort measures (e.g., midazolam and morphine) in the eWHWD group reflects a greater emphasis on symptom control in imminently dying patients, but also points to potential variability in how comfort care is applied depending on timing and patient acuity. Implications for Practice Our findings highlight the need for better EOL care integration into ED protocols. The stark contrast between the rapid pace of emergency care and the reflective process required for WHWD decisions creates systemic tension. To address this, advance care planning must be strengthened in upstream care settings (e.g., general practice, long-term care facilities). This echoes recommendations by international bodies, including the American College of Emergency Physicians and European Resuscitation Council, which emphasise early goals-of-care discussions in chronic disease management [ 23 – 25 ]. Enhanced training for ED staff in palliative care principles, earlier identification of patients with chronic life-limiting illnesses, and broader use of decision aids such as the one introduced in France in 2020 could help align care more closely with patient values [ 9 ]. The limited documentation of advance directives and designated trusted persons in our study highlights a gap between national policy and actual clinical practice, underscoring the need for targeted interventions. Limitations This study has several limitations. First, its retrospective, single-centre design limits generalizability. Second, we relied on electronic medical records, which may incompletely capture the nuances of clinical judgment and discussions with patients or families. Third, while the timing of WHWD was used to categorise patients, it may also reflect institutional workflow factors not accounted for in our analysis. Finally, unmeasured confounding cannot be ruled out, despite multivariable adjustment. Conclusion In this retrospective study, early WHWD decisions were associated with more severe clinical presentations and higher short-term mortality, while late rulings were linked to better adjusted long-term survival. These findings emphasise the need for thoughtful, patient-centred EOL decision-making in EDs and better anticipatory planning across the healthcare continuum. Strengthening palliative care integration and improving communication tools may help reconcile the realities of emergency care with the goals of dignified end-of-life experiences. Abbreviations CI Confidence Interval ED Emergency Department EOL End-Of-Life HR Hazard Ratio IQR. Interquartile Range WHWD withholding or withdrawing Declarations Ethics approval and consent to participate The work conformed to the Declaration of Helsinki. The informed consent was waived by the institutional review board called Assistance Publique des Hôpitaux de Paris Clinical Data Warehouse (AP-HP CDW) Scientific and Ethics Committee (Conseil Scientifique et Ethique; IRB number : 00011591). Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interest The authors declare that they have no competing interest. Funding The authors received no funding from an external source. Authors' contributions JS : Data curation; Formal analysis; Investigation; Methodology; Visualization; Writing - review & editing. Pradeebane VA: Formal analysis; Supervision; Validation; Visualization; Writing - review & editing. Prabakar VA: Conceptualization; Data curation; Formal analysis; Methodology; Project administration; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing. Acknowledgements Not applicable References Institut national de la statistique et des études économiques. Évolution du nombre de décès entre le 1er janvier et le 31 décembre 2022 – Nombre de décès quotidiens | Insee. 2023. https://www.insee.fr/fr/statistiques/6206305?sommaire=4487854#tableau-figure2 . Accessed 3 Sep 2024. Inspection Générale des Affaires Sociales. La mort à l’hôpital.|IGAS. 2009. https://www.igas.gouv.fr/La-mort-a-l-hopital.html . Accessed 3 Sep 2024. Gomes B, Calanzani N, Gysels M, Hall S, Higginson IJ. Heterogeneity and changes in preferences for dying at home: a systematic review. BMC Palliat Care. 2013;12:7. https://doi.org/10.1186/1472-684X-12-7 . Commission de réflexion sur la fin de vie en France. Rapport a François hollande, président de la république française; 2012. Rothmann C, Evrard D. La mort aux urgences. J européen des urgences. 2005;18:3–9. Le Conte P, Riochet D, Batard E, Volteau C, Giraudeau B, Arnaudet I, et al. Death in emergency departments: a multicenter cross-sectional survey with analysis of withholding and withdrawing life support. Intensive Care Med. 2010;36:765–72. https://doi.org/10.1007/s00134-010-1800-1 . Le Conte P, Batard E, Pinaud V, Evain Y, Potel G. Décisions de limitation ou d’arrêt des thérapeutiques actives dans les services d’urgence. Réanimation. 2008;17:802–6. https://doi.org/10.1016/j.reaurg.2008.09.005 . Article R712-65. - Code de la santé publique - Légifrance. https://www.legifrance.gouv.fr/codes/article_lc/LEGIARTI000006802859 . Accessed 10 Sep 2024. Reignier J, Feral-Pierssens A-L, Boulain T, Carpentier F, Le Borgne P, Del Nista D, et al. Withholding and withdrawing life-support in adults in emergency care: joint position paper from the French Intensive Care Society and French Society of Emergency Medicine. Ann Intensive Care. 2019;9:105. https://doi.org/10.1186/s13613-019-0579-7 . SFMU SFAP. Procédure d’aide à la décision de Limitation et Arrêt des thérapeutiques lors d’une prise en charge en urgence. Fiche Mémo. 2020. Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE-acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med. 1981;9:591–7. https://doi.org/10.1097/00003246-198108000-00008 . Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–29. Azoulay E, Pochard F, Garrouste-Orgeas M, Moreau D, Montesino L, Adrie C, et al. Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death. Intensive Care Med. 2003;29:1895–901. https://doi.org/10.1007/s00134-003-1989-3 . Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow H-H, Hovilehto S, et al. End-of-life practices in European intensive care units: the Ethicus Study. JAMA. 2003;290:790–7. https://doi.org/10.1001/jama.290.6.790 . Chambers N, Curtis JR, Rubenfeld GD. Managing Death in the ICU: The Transition from Cure to Comfort. Crit Care. 2002. https://doi.org/10.1186/CC1479 . Hua M, Halpern SD, Gabler NB, Wunsch H. Effect of ICU Strain on Timing of Limitations in Life-Sustaining Therapy and Death. Intensive Care Med. 2016;42:987–94. https://doi.org/10.1007/s00134-016-4240-8 . Azoulay E, Metnitz B, Sprung CL, Timsit J-F, Lemaire F, Bauer P, et al. End-of-life practices in 282 intensive care units: data from the SAPS 3 database. Intensive Care Med. 2009;35:623–30. https://doi.org/10.1007/s00134-008-1310-6 . Bosslet GT, Pope TM, Rubenfeld GD, Lo B, Truog RD, Rushton CH, et al. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med. 2015;191:1318–30. https://doi.org/10.1164/rccm.201505-0924ST . Ferrand E, Robert R, Ingrand P, Lemaire F, French LATAREA, Group. Withholding and withdrawal of life support in intensive-care units in France: a prospective survey. French LATAREA Group. Lancet. 2001;357:9–14. https://doi.org/10.1016/s0140-6736(00)03564-9 . Le Guen J, Boumendil A, Guidet B, Corvol A, Saint-Jean O, Somme D. Are elderly patients’ opinions sought before admission to an intensive care unit? Results of the ICE-CUB study. Age Ageing. 2016;45:303–9. https://doi.org/10.1093/ageing/afv191 . Auriemma CL, Nguyen CA, Bronheim R, Kent S, Nadiger S, Pardo D, et al. Stability of End-of-Life Preferences: A Systematic Review of the Evidence. JAMA Intern Med. 2014;174:1085–92. https://doi.org/10.1001/jamainternmed.2014.1183 . Baumann A, Audibert G, Claudot F, Puybasset L. Ethics review: End of life legislation – the French model. Crit Care. 2009;13:204. https://doi.org/10.1186/cc7148 . Sudore RL, Fried TR. Redefining the Planning in Advance Care Planning: Preparing for End-of-Life Decision Making. Ann Intern Med. 2010;153:256–61. https://doi.org/10.7326/0003-4819-153-4-201008170-00008 . Grudzen CR, Richardson LD, Hopper SS, Ortiz JM, Whang C, Morrison RS. Does palliative care have a future in the emergency department? Discussions with attending emergency physicians. J Pain Symptom Manage. 2012;43:1–9. https://doi.org/10.1016/j.jpainsymman.2011.03.022 . Grudzen CR, Richardson LD, Morrison M, Cho E, Morrison RS. Palliative care needs of seriously ill, older adults presenting to the emergency department. Acad Emerg Med. 2010;17:1253–7. https://doi.org/10.1111/j.1553-2712.2010.00907.x . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 09 Sep, 2025 Reviews received at journal 04 Sep, 2025 Reviewers agreed at journal 04 Sep, 2025 Reviewers invited by journal 04 Sep, 2025 Editor invited by journal 18 Aug, 2025 Editor assigned by journal 13 Aug, 2025 Submission checks completed at journal 13 Aug, 2025 First submitted to journal 12 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7357429","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":513284165,"identity":"b6b4cb5c-ef8b-44e1-87d0-ac2ea2d9a5ce","order_by":0,"name":"Joseph Sinoquet","email":"","orcid":"","institution":"Beaujon University Hospital, Greater Paris Hospitals APHP","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Sinoquet","suffix":""},{"id":513284166,"identity":"5cd9a5ba-7c2c-422c-9112-af9424a5b02b","order_by":1,"name":"Pradeebane Vaittinada Ayar","email":"","orcid":"","institution":"CNRS/CEA/UVSQ, UMR8212, Université Paris-Saclay","correspondingAuthor":false,"prefix":"","firstName":"Pradeebane","middleName":"Vaittinada","lastName":"Ayar","suffix":""},{"id":513284167,"identity":"96ea8d54-d945-447f-b73a-51c0fe95722b","order_by":2,"name":"Prabakar Vaittinada Ayar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYJCCAwwMEkAqgfEBkOThI0rLgQSwFmYDkBY24qxJAJEJbCCNDAS1mEskPzz88YdFHn978rPKrzl2MmwMzA8f3cCjxXJGmgHIYcUSZ56Z3Zbdlgx0GJuxcQ4eLQZnDoC1JDbcSDC7LbmNGaiFh00av5bjH8Ba5t9I/1Ysua2eCC3HeyC2bLiRY8b4cdthwlos23sKDpxJk0jceOZNsTTjtuM8bMwE/GLOzL75Q4VNXeK84+kbP/7cVm3Pz9788DFehyFzmHnAJB7lGFoYfxBQPQpGwSgYBSMTAADxik4MkpBp8wAAAABJRU5ErkJggg==","orcid":"","institution":"Beaujon University Hospital, Greater Paris Hospitals APHP","correspondingAuthor":true,"prefix":"","firstName":"Prabakar","middleName":"Vaittinada","lastName":"Ayar","suffix":""}],"badges":[],"createdAt":"2025-08-12 15:38:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7357429/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7357429/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91187672,"identity":"8bd3c167-7254-4888-ba58-a5f6af70f6e9","added_by":"auto","created_at":"2025-09-12 14:20:50","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26717,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart\u003c/p\u003e","description":"","filename":"groupimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7357429/v1/fc175138a1f902a8b5c8b68f.jpeg"},{"id":91187678,"identity":"1d81863b-9e0d-47dc-8cdb-f93be2b1ebbd","added_by":"auto","created_at":"2025-09-12 14:20:50","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":487654,"visible":true,"origin":"","legend":"\u003cp\u003eShort \u0026amp; long-term mortality according to the time of Withholding/Withdrawing (WHWD). Unadjusted and adjusted HRs and 95% confidence intervals for the association between mortality and the WHWD timing.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7357429/v1/3941d55b850a1f66b2f2c267.jpeg"},{"id":91189471,"identity":"1e347523-b563-49d3-b383-d40711d6c584","added_by":"auto","created_at":"2025-09-12 14:28:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1610226,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7357429/v1/bee54365-00ad-43d6-92d8-b031deb84d6a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Early decision effect of withholding and/or withdrawing life-sustaining treatment on emergency department patients’ short- and long-term outcomes: a retrospective analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEach year, approximately 650,000 deaths occur in France [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite most patients expressing a preference to die at home, 58% of these deaths still took place in hospitals, as reported by the French General inspection of Social Affairs in 2009 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This was even though patients at the end of life (EOL) generally wanted to die at home [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This discrepancy between patients' end-of-life wishes and the reality is likely stemmed from a lack of anticipation and insufficient resources to support home care in the final days. Notably, 16% of hospital deaths occurred within the first 24 hours of admission, often in emergency departments (ED) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While deaths accounted for only about 0.2% of all ED visits [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], this still represented approximately 40,000 deaths out of 20.3\u0026nbsp;million emergency visits in France in 2021. Caring for EOL patients in such settings demands significant time, material, and human resources, placing a significant emotional burden on families and healthcare teams. Importantly, between 79\u0026ndash;87% of these deaths are preceded by decisions to withhold or withdraw life-sustaining treatments [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The primary mission of emergency medical services is to provide care for all individuals in emergency situations, including psychiatric emergencies, 24/7, without selection, especially in distress or life-threatening cases [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This mission necessitated a specific organisational structure designed to meet various constraints. However, these constraints often create an \"emergency environment\" which is not conducive to make withholding or withdrawing (WHWD) decisions or offering appropriate EOL care. In this fast-paced setting, the need to make and implement decisions swiftly, yet carefully, is critical. Additionally, the organisation of care heavily relies on discharge rates, which hinge on the availability of beds in other units. Frequent bed shortages contribute to overcrowding in EDs, forcing patients to wait in suboptimal conditions, with limited privacy and calm. In response to these challenges, the French Intensive Care Society and the French Society of Emergency Medicine published a joint position paper in 2018 addressing WHWD decisions in emergency care [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The authors acknowledged the tension between regulatory requirements and everyday realities in emergency departments. The position paper emphasised the critical importance of understanding the daily realities in EDs and respecting the patient's wishes when making WHWD decisions. It highlighted the need to review patients' medical records and assess their autonomy and cognitive state before deciding. The position paper also covered the use of deep sedation in emergency settings, stressing that the procedure should be thoroughly documented in the medical record and that physicians must ensure the patient's relatives fully understand the process. In 2020, the SFMU, in collaboration with the French Society of Palliative Care (SFAP), published a paper-based WHWD decision aid specifically designed for emergency settings [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, data on the total number of WHWD implementations remained scarce. Most studies have focused on patients who died in emergency departments following a WHWD decision. However, there is limited information on patients for whom a WHWD was initiated but who survived beyond their ED stay.\u003c/p\u003e\u003cp\u003eThe aim of this study was to assess the effect of WHWD decision timing on short- and long-term outcomes of ED patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis retrospective, observational, single-centre study was conducted within the Emergency Department of Beaujon Hospital (Assistance Publique des h\u0026ocirc;pitaux de Paris (AP-HP)). The data collection period spanned from January 1, 2020, to December 31, 2021.\u003c/p\u003e\u003cp\u003eDemographic, clinical, discharge, transfer, WHWD and death data were extracted from the Orbis\u0026reg; medical data processing software (healthcare software, Dedalus, Florence, Italy) or by contacting the hospital if the department does not use Orbis\u0026reg;. Autonomy for activities of daily living was assessed using the KNAUS classification [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] (annexe 1). This classification system describes the level of care required by older and disabled individuals, and ranges from A (completely autonomous) to D (most dependent). Patients classified as KNAUS A or B represent individuals who do not experience problems with autonomy in their daily tasks. The APACHE II score [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], the presence of legal protection guardianship, and the presence of daily nurse visits or home care were determined from the patient\u0026rsquo;s medical record.\u003c/p\u003e\u003cp\u003eTo be included, adult patients hospitalised after their ED visit must be admitted to the observation unit (OU) in association with a mention of a WHWD of the life-sustaining treatment in the ED medical record. The time between arrival and the WHWD decision was extracted from Orbis\u0026reg;, and the comparison of patients was done according to the median time of this decision. After WHWD, a follow-up was conducted first, for 7 and 28 days, up to the point of death or discharge from the hospital. And a follow-up was extended to 90 days and one year. The primary outcome was 28-day all-cause mortality after the WHWD decision.\u003c/p\u003e\u003cp\u003eEthics\u003c/p\u003e\u003cp\u003eThe work is conformed to the Declaration of Helsinki. The study was approved by the Scientific and Ethical Committee of Assistance Publique \u0026ndash; Hopitaux de Paris (AP-HP) clinical data warehouse (IRB00011591). The database was authorised by the National Freedom and Informatics Commission (CNIL Number: 1980120). Assistance Publique \u0026ndash; Hopitaux de Paris (AP-HP) clinical data warehouse initiative ensures patients\u0026rsquo; information and consent regarding the approved studies through a transparency portal following European Regulation on data protection and authorisation (number 1980120) from the National Freedom and Informatics Commission. The need for informed consent was waived by the Scientific and Ethical Committee of Assistance Publique \u0026ndash; Hopitaux de Paris (AP-HP) clinical data warehouse, because of the retrospective nature of the study. The study was retrospectively registered at ClinicalTrials.gov on 4 August 2025 (NCT07115719).\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eContinuous variables are expressed as median [interquartile range (IQR)]. Categorical variables are presented as a number (percentage). The normality of all variables was checked using the Shapiro-Wilk test. Group characteristics were compared using the t-test for normally distributed continuous variables, the Mann-Whitney test for non-normally distributed continuous variables, or the χ\u0026sup2; test for categorical variables. Hazard ratio (HR) and 95% confidence interval (95% CI) for 7, 28, 90-day and 1-year all-cause mortality were calculated using a Cox proportional hazards regression model. Variables with a p\u0026thinsp;\u0026lt;\u0026thinsp;0.10 on univariate analysis were entered into the Cox regression model to describe how the factors jointly impact survival. We also kept comorbidity as a key confounder. The optimal model selection involved finding the best compromise between the number of factors to keep and the accuracy of the Cox regression analysis. The model was adjusted with age, sexe, dementia, active cancer, KNAUS scale, APACHE II score and home care. The proportional hazards assumption was checked using statistical tests based on the scaled Schoenfeld residuals. Analyses were performed using R\u0026reg; software (R Development Core Team, R Foundation for Statistical Computing, Vienna, Austria). A two-sided p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e\u003cp\u003eSample Size\u003c/p\u003e\u003cp\u003eThe estimated population is 140 patients, considering the 0.2% mortality rate in the emergency department, and the 35,000 annual visits at the Beaujon emergency department over two years.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween January 1, 2020, and December 31, 2021, there were 64,239 emergency department (ED) visits at Beaujon Hospital. Among these, 7,707 patients were hospitalised, and 354 cases involving a decision to limit or withdraw life-sustaining treatments (WHWD) were included in the study (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe median age of included patients was 83 years (IQR 72\u0026ndash;90), and 53% were women (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The median time between ED arrival and WHWD decision was 242 minutes (IQR 119\u0026ndash;426). The median time to decision was approximately 2 hours in the eWHWD (early WHWD) group and 7 hours in the lWHWD (late WHWD) group. Sixty-one per cent of patients lived at home, while 39% were institutionalised. According to the Knaus classification, 7% of patients were class A or B, 46% class C, and 46% class D. Patients classified as Knaus D were more frequent in the eWHWD group (56% vs. 37%; p\u0026thinsp;=\u0026thinsp;0.0005), while class C was more common in the lWHWD group (56% vs. 35%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003cp\u003eRegarding medical history, dementia was present in 50% of patients, heart disease in 40%, and active cancer in 26%. Dementia was more prevalent in the eWHWD group (57% vs. 44%; p\u0026thinsp;=\u0026thinsp;0.014), while active cancers were more frequent in the lWHWD group (19% vs. 10%; p\u0026thinsp;=\u0026thinsp;0.026). Seventy-seven per cent of patients were transported by ambulance, and 19% by Emergency medical service (EMS). Medicalised transport was more common in the eWHWD group (29% vs. 10%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The most frequent reasons for ED admission were respiratory (61%) and neurological (46%). Patients in the eWHWD group more often presented with respiratory (56% vs. 40%; p\u0026thinsp;=\u0026thinsp;0.004), circulatory (39% vs. 23%; p\u0026thinsp;=\u0026thinsp;0.001), and neurological failures (31% vs. 15%; p\u0026thinsp;=\u0026thinsp;0.0003). Clinically, early WHWD patients had lower mean arterial pressure and Glasgow scores and required more oxygen. The median APACHE II score for all patients was 16. The score was significantly higher in eWHWD patients (median 18 vs. 14.5; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline characteristics\u0026nbsp;\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAvailable data N (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEWHWD\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;176)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLWHWD\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;178)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAge Median (Q1 - Q3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 (72\u0026ndash;90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 (75\u0026ndash;92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81 (70\u0026ndash;89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTime between Arrival and WHWD decision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e242 (119\u0026ndash;426)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117 (51\u0026ndash;181)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e414 (311\u0026ndash;696)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSexe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e165 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e189 (53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eLiving place\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e216 (61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e114 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNursing Home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e138 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSocial isolation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLegal protection guardianship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHome care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e352 (99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e250 (71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e141 (81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e109 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eKnaus scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e347 (98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e159 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e161 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"11\"\u003e\n \u003cp\u003eMedical history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePsychiatric disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"11\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDementia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e178 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeurodegenerative disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e140 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRespiratory disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChronicle kidney disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLiver disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImmunodefiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eActive cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eED presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e282 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e158(89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-presented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHospitalisation during last 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e203 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e103 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"12\"\u003e\n \u003cp\u003eMain complaint\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDyspnea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"12\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e217 (61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypotension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeurologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e164 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e103 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbdomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMetabolic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraumatology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHaemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e187 (53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eToxicology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsthenia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultiple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e310 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e153 (87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e157 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eClinical parameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTemperature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e350 (99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.6 (36.1\u0026ndash;37.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.6 (36\u0026ndash;37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.6 (36.2\u0026ndash;37.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean blood pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83.5 (64\u0026ndash;100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79 (60\u0026ndash;97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85.5 (70\u0026ndash;103)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeart rate (bpm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94 (80\u0026ndash;108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98 (81.5\u0026ndash;110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93 (78\u0026ndash;107)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGlasgow coma scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (9\u0026ndash;15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (7\u0026ndash;14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (13\u0026ndash;15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOxygen need (L/min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (0\u0026ndash;9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (0\u0026ndash;12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (0\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"7\"\u003e\n \u003cp\u003eLaboratory tests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaO2 (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e162 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82 (67\u0026ndash;119)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91 (70\u0026ndash;130)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77 (66\u0026ndash;108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e162 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.36 (7.28\u0026ndash;7.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.34 (7.26\u0026ndash;7.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.37 (7.3\u0026ndash;7.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.094\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSodium (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e334 (94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e138 (134\u0026ndash;142)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e139 (134\u0026ndash;142)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e138 (134\u0026ndash;142)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePotassium (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e334 (94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4 (3.9\u0026ndash;5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.5 (3.9\u0026ndash;5.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4 (3.9\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCreatinine (\u0026micro;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e334 (94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115 (72\u0026ndash;199)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131 (74\u0026ndash;209)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e105.5 (71\u0026ndash;176)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeucocytes (/mm\u003csup\u003e3)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e330 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.6 (8.6\u0026ndash;18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.8 (9.3\u0026ndash;20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.9 (8.3\u0026ndash;17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHaemoglobin (g/dl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e330 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.7 (9.8\u0026ndash;13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.9 (10.1\u0026ndash;13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.7 (9.7\u0026ndash;13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAPACHE II Median (Q1 - Q3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e334 (94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (13\u0026ndash;21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (14.5\u0026ndash;22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.5 (12\u0026ndash;18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\"\u003e\n \u003cp\u003eAPACHE I: Acute Physiologic Assessment and Chronic Health Evaluation Scoring System II\u003c/p\u003e\n \u003cp\u003eEMS: emergency medical service\u003c/p\u003e\n \u003cp\u003eGIR: groupe iso-ressource\u003c/p\u003e\n \u003cp\u003eWHWD: Withholding/Withdrawing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe principle of collegiality in WHWD decisions was followed in 84% of cases, with no difference between groups (Table 2). Intensivists were the most frequent medical partners (45%). Most patients (77%) were deemed unable to express their preferences due to cognitive disorders or altered consciousness. The eWHWD group had a lower proportion of patients considered capable of expressing their wishes (14% vs. 33%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but overall patient involvement was low (7%) and not significantly different between groups. Advance directives were recorded in only 3% of cases, and a trusted person was identified in 13%. There was no significant difference between groups regarding advance directive presence, identification of a trusted person, or physician involvement. The main reasons cited for WHWD were disproportionate care (86%), poor anticipated quality of life (44%), and terminal prognosis (43%). Poor quality of life was oftentimes cited in eWHWD decisions (50% vs. 37%; p\u0026thinsp;=\u0026thinsp;0.014). Supportive care, including oxygen therapy and fluid resuscitation, was more frequently administered in the eWHWD group. These therapies and non-invasive ventilation were also more often limited in that group. WHWD involved limitation of treatment in 88% of cases and withdrawal in 12%. Only 7% of patients were evaluated by the hospital palliative care team, with no significant difference between groups. Pain assessment was recorded in 81% of patients, with no group differences. Comfort care measures included sedation with Midazolam in 21% of patients and analgesia with Morphine in 29%. Both were used more frequently in the eWHWD group: Midazolam (27% vs. 15%; p\u0026thinsp;=\u0026thinsp;0.0009) and Morphine (38% vs. 21%; p\u0026thinsp;=\u0026thinsp;0.008).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eEnd of life decision process and treatment\u0026nbsp;\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAvailable data N (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEWHWD\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;176)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLWHWD\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;178)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eCollegial WHWD process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e297 (84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e151 (86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e146 (82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\n \u003cp\u003eParticipant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMany\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntensivist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e160 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGerontologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOncologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOrther ED physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePatient able to decide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eCriteria for assessing patient incapacity to make a decision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeurocognitive disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConfusion ou coma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e119 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePatient directly involved in making decisions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAdvanced health care directives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eKnown surrogate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eInvolvement of the primary care physician in decision-making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eInvolvement of the specialist in decision-making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eInvolvement of the paramedical team in decision-making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAssessment of autonomy and quality of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e332 (94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003eReason of WHWD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePredictable short-term mortality linked to an incurable chronic disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e151 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIrreversibility of the acute condition.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCurrent or future quality of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e154 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCare considered too invasive given the risk-benefit ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e303 (86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e148 (84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e155 (87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily request\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"9\"\u003e\n \u003cp\u003eLife-sustaining treatments initiated before WHWD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCPR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"9\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOrotracheal intubation and mechanical ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-invasive ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh-flow oxygen therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCatecholamines infusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFluid resuscitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e105 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRenal replacement therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmergency surgery or endoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e201 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e112 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\n \u003cp\u003eOther treatments initiated before WHWD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow-flow oxygen therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e241 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125 (71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e116 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeripheral venous catheter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e347 (98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e169 (96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e178 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVenous blood tests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e333 (96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e155 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e178 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArterial blood tests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e166 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSubcutaneous infusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.060\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAntibiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e229 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117 (66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e112 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnticoagulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\n \u003cp\u003eLife-sustaining treatments stopped or not initiated after WHWD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCPR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e176 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e178 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOrotracheal intubation and mechanical ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e353 (99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e176 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e177 (99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-invasive ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e161 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94 (53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh-flow oxygen therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCatecholamines infusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e327 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e167 (95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e160 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFluid resuscitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRenal replacement therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e332 (94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e167 (95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e165 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmergency surgery or endoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e269 (76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e138 (78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\n \u003cp\u003eOther treatments stopped or not initiated after WHWD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow-flow oxygen therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeripheral venous catheter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVenous blood tests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArterial blood tests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSubcutaneous infusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAntibiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnticoagulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eWithdrawal of life-sustaining treatments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePatient known by the palliative care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePatient assessed by the palliative care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAssessment of physical or mental pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e287 (81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e142 (81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e145 (81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003ePalliative care initiated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidazolam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e354 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMorphin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eScopolamin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\"\u003e\n \u003cp\u003eCPR: Cardiopulmonary Resuscitation; ED: Emergency department; WHWD: Withholding/Withdrawing\u003c/p\u003e\n \u003cp\u003eData are presented as median (interquartile range) for continuous data and as number (percentage) for categorical data. The P-value to the right represent the test for trend determined by either Wilcoxon rank-sum (continuous data) or chisquare [categorical data]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eRegarding outcomes (Table 3), 31% of patients died in the ED, 32% died in downstream units, and 35% were discharged alive. ED mortality was higher in the eWHWD group (39% vs. 22%; p\u0026thinsp;=\u0026thinsp;0.0005), while downstream unit mortality was higher in the lWHWD group (38% vs. 27%; p\u0026thinsp;=\u0026thinsp;0.030). Discharge rates were similar between groups. The mortality of the whole population at 7, 28, 90-day and 1-year was 51%, 70%, 82% and 90% respectively. At 7 days, 58% of eWHWD patients had died, compared to 44% in the late group (p\u0026thinsp;=\u0026thinsp;0.008). Seventy-six per cent of the overall eWHWD patients died within 28 days, compared to 65% in the lWHWD group (p\u0026thinsp;=\u0026thinsp;0.022). There was no significant difference at 90 days or one year.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eoutcomes\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAvailable data N (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEWHWD\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;176)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLWHWD\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;178)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eED mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e353 (99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e108 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003ePost-ED disposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute geriatric ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e245 (69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e119 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInternal medicine ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHome / Nursing Home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePalliative care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMortality in admission ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e349 (98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e114 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003ePost ward disposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHome / Nursing Home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e101 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79 (79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePalliative care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDischarged Alive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e347 (98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e7\u0026ndash;days mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e347 (98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e177 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100 (58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e28\u0026ndash;days mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e344 (97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e242 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e130 (76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e112 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e90\u0026ndash;days mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e329 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e270 (82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e143 (86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e127 (78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1\u0026ndash;year mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e326 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e295 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e152 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e143 (89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\"\u003e\n \u003cp\u003eED: Emergency department; WHWD: Withholding/Withdrawing\u003c/p\u003e\n \u003cp\u003eData are presented as median (interquartile range) for continuous data and as number (percentage) for categorical data. The P-value to the right represent the test for trend determined by either Wilcoxon rank-sum (continuous data) or chisquare [categorical data]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe relationship between the timing of a WHWD decision and survival favoured the late group decision regarding the short-term prognostic (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The unadjusted hazard ratio (HR) was lower in lWHWD for 7- and 28-day survival, respectively HR\u0026thinsp;=\u0026thinsp;0.61; 95% CI (0.45 to 0.82) and 0.66; 95% CI (0.51 to 0.85). The adjusted HR for short-term prognostic stay in favour of late decision group. For long-term prognostic (90 days and 1 year survival), there was no difference between the 2 groups according to the unadjusted HR (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). But after adjustment with the age, sex, dementia, active cancer, KNAUS scale, APACHE II score, and home care, the HR at 90-day and one year was significantly in favour of lWHWD group, respectively adjusted HR\u0026thinsp;=\u0026thinsp;0.76; 95% CI (0.72 to 0.81) and 0.86; 95% CI (0.81 to 0.91).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the outcomes of early versus late decisions to limit or withdraw life-sustaining treatments (WHWD) in emergency department (ED) patients. Our findings reveal significant differences in patient characteristics, care pathways, and short-term mortality between early WHWD (eWHWD) and late WHWD (lWHWD) groups, underscoring the complexity of end-of-life (EOL) decision-making in the emergency setting.\u003c/p\u003e\n\u003ch3\u003eTiming and Mortality Outcomes\u003c/h3\u003e\n\u003cp\u003eThe median delay to WHWD decision was significantly shorter in the eWHWD group (approximately 2 hours) compared to the lWHWD group (7 hours). This timing was closely associated with early mortality. Specifically, eWHWD patients had significantly higher mortality at 7 and 28 days. While this may initially suggest a negative impact of earlier decisions, it likely reflects the severity of illness and the acute context in which these decisions were made, rather than premature decision-making. These results align with findings by Hua et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] who reported higher early mortality among patients with rapidly made WHWD decisions in intensive care units.\u003c/p\u003e\u003cp\u003eNotably, after adjusting for confounders, late WHWD remained independently associated with improved survival even at 90 days and 1 year, suggesting that, when possible, a delayed and more comprehensive decision-making process might be beneficial. However, it is critical to note that the latter group may benefit from more complete diagnostic evaluations, discussions with families, and collegial processes, all of which may improve the quality of decision-making rather than merely delay it [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eDecision-Making Practices and Ethical Considerations\u003c/h3\u003e\n\u003cp\u003e Despite legal and professional guidelines emphasising patient involvement, our study revealed a low patient involvement rate (7%) in WHWD decisions, with only 3% having documented advance directives. These findings underscore persistent challenges in anticipatory EOL planning and communication, especially in emergency settings where many patients arrive with impaired consciousness or no clear medical history [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The low uptake of advance directives is also echoed in broader French studies[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and may reflect societal, cultural, or systemic barriers to proactive care planning.\u003c/p\u003e\u003cp\u003eMoreover, while the collegiality principle was applied in 84% of cases consistent with French legal requirements consultation with palliative care teams remained rare (7%). This underutilization has been previously noted [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and it may stem from the limited availability of palliative care professionals in EDs, especially outside regular working hours. The higher use of comfort measures (e.g., midazolam and morphine) in the eWHWD group reflects a greater emphasis on symptom control in imminently dying patients, but also points to potential variability in how comfort care is applied depending on timing and patient acuity.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eImplications for Practice\u003c/h2\u003e\u003cp\u003eOur findings highlight the need for better EOL care integration into ED protocols. The stark contrast between the rapid pace of emergency care and the reflective process required for WHWD decisions creates systemic tension. To address this, advance care planning must be strengthened in upstream care settings (e.g., general practice, long-term care facilities). This echoes recommendations by international bodies, including the American College of Emergency Physicians and European Resuscitation Council, which emphasise early goals-of-care discussions in chronic disease management [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEnhanced training for ED staff in palliative care principles, earlier identification of patients with chronic life-limiting illnesses, and broader use of decision aids such as the one introduced in France in 2020 could help align care more closely with patient values [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The limited documentation of advance directives and designated trusted persons in our study highlights a gap between national policy and actual clinical practice, underscoring the need for targeted interventions.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study has several limitations. First, its retrospective, single-centre design limits generalizability. Second, we relied on electronic medical records, which may incompletely capture the nuances of clinical judgment and discussions with patients or families. Third, while the timing of WHWD was used to categorise patients, it may also reflect institutional workflow factors not accounted for in our analysis. Finally, unmeasured confounding cannot be ruled out, despite multivariable adjustment.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this retrospective study, early WHWD decisions were associated with more severe clinical presentations and higher short-term mortality, while late rulings were linked to better adjusted long-term survival. These findings emphasise the need for thoughtful, patient-centred EOL decision-making in EDs and better anticipatory planning across the healthcare continuum. Strengthening palliative care integration and improving communication tools may help reconcile the realities of emergency care with the goals of dignified end-of-life experiences.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence Interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eED\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEmergency Department\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEOL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEnd-Of-Life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHazard Ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIQR.\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInterquartile Range\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHWD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ewithholding or withdrawing\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe work conformed to the Declaration of Helsinki. The informed consent was waived by the institutional review board called Assistance Publique des H\u0026ocirc;pitaux de Paris Clinical Data Warehouse (AP-HP CDW) Scientific and Ethics Committee (Conseil Scientifique et Ethique; IRB number : 00011591).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interest\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest.\u003c/p\u003e\n\u003cp\u003eFunding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors received no funding from an external source.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJS\u003c/strong\u003e: Data curation; Formal analysis; Investigation; Methodology; Visualization; Writing - review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePradeebane VA:\u003c/strong\u003e Formal analysis; Supervision; Validation; Visualization; Writing - review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrabakar VA:\u003c/strong\u003e Conceptualization; Data curation; Formal analysis; Methodology; Project administration; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eInstitut national de la statistique et des \u0026eacute;tudes \u0026eacute;conomiques. \u0026Eacute;volution du nombre de d\u0026eacute;c\u0026egrave;s entre le 1er janvier et le 31 d\u0026eacute;cembre 2022\u0026thinsp;\u0026ndash;\u0026thinsp;Nombre de d\u0026eacute;c\u0026egrave;s quotidiens | Insee. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.insee.fr/fr/statistiques/6206305?sommaire=4487854#tableau-figure2\u003c/span\u003e\u003cspan address=\"https://www.insee.fr/fr/statistiques/6206305?sommaire=4487854#tableau-figure2\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Acad Emerg Med. 2010;17:1253\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1553-2712.2010.00907.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1553-2712.2010.00907.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Emergency department, end of life, withholding or withdrawing life-sustaining treatments","lastPublishedDoi":"10.21203/rs.3.rs-7357429/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7357429/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIn France, a significant proportion of end-of-life (EOL) decisions occur in emergency departments (EDs), where time constraints and limited resources may hinder optimal care. Although withholding or withdrawing life-sustaining treatments (WHWD) is common in this context, the impact of timing on patient outcomes remains unclear. The study assessed how the timing of WHWD decisions influences short- and long-term outcomes among ED patients.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eWe conducted a retrospective, observational study at Beaujon Hospital\u0026rsquo;s ED (Paris, France) between January 2020 and December 2021. We included all adult patients admitted to the observation unit with a WHWD decision. Patients were categorized into early (eWHWD) and late (lWHWD) groups based on the median time to decision. The primary endpoint was 28-day all-cause mortality. Cox regression was used for survival analysis, adjusting for age, sex, comorbidities, functional status, and severity of illness.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eWHWD was decided in 354 patients. Patients in the eWHWD group (n\u0026thinsp;=\u0026thinsp;176) were older, more functionally impaired, and had higher illness severity than those in the lWHWD group (n\u0026thinsp;=\u0026thinsp;178). Early decisions occurred within a median of 2 hours versus 7 hours in the late group. Short-term mortality was significantly higher in the eWHWD group at 7 days (58% vs. 44%) and 28 days (76% vs. 65%). After adjustment, late WHWD remained independently associated with better survival at 7-days, 28-days, 90-days and 1-year. Respectively adjusted Hazard Ratios were equal to 0.71; 95% confidence interval (CI) (0.66 to 0.76), 0.73; 95% CI (0.68 to 0.78), 0.76; 95% CI (0.72 to 0.81) and 0.86; 95% CI (0.81 to 0.91).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eEarly WHWD decisions reflect more severe patient conditions and are linked to poorer short and long-term outcomes. Enhancing advance care planning and integrating palliative care into ED practices may improve decision quality and align care with patient values.\u003c/p\u003e","manuscriptTitle":"Early decision effect of withholding and/or withdrawing life-sustaining treatment on emergency department patients’ short- and long-term outcomes: a retrospective analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-12 14:20:45","doi":"10.21203/rs.3.rs-7357429/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"34899694086733540466631197689329555094","date":"2025-09-09T09:54:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-04T12:07:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314954720673821596540550613280564681220","date":"2025-09-04T11:40:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-04T09:41:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-18T10:38:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-14T03:44:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-14T03:43:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2025-08-12T15:28:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c0c300d9-64f8-4a49-bafa-c8467934069f","owner":[],"postedDate":"September 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-12T14:20:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-12 14:20:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7357429","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7357429","identity":"rs-7357429","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}