Quality of Life Before Intensive Care Unit Admission
Introduction: Predicting whether a critically ill patient will survive intensive care treatment remains difficult. The advantages of a validated strategy to identify those patients who will not benefit from intensive care unit (ICU) treatment are evident. Providing critical care treatment to patients who will ultimately die in the ICU is accompanied by an enormous emotional and physical burden for both patients and their relatives. The purpose of the present study was to examine whether health-related quality of life (HRQOL) before admission to the ICU can be used as a predictor of mortality.
Methods: We conducted a prospective cohort study in a university-affiliated teaching hospital. Patients admitted to the ICU for longer than 48 hours were included. Close relatives completed the Short-form 36 (SF-36) within the first 48 hours of admission to assess pre-admission HRQOL of the patient. Mortality was evaluated from ICU admittance until 6 months after ICU discharge. Logistic regression and receiver operating characteristic analyses were used to assess the predictive value for mortality using five models: the first question of the SF-36 on general health (model A); HRQOL measured using the physical component score (PCS) and mental component score (MCS) of the SF-36 (model B); the Acute Physiology and Chronic Health Evaluation (APACHE) II score (an accepted mortality prediction model in ICU patients; model C); general health and APACHE II score (model D); and PCS, MCS and APACHE II score (model E). Classification tables were used to assess the sensitivity, specificity, positive and negative predictive values, and likelihood ratios.
Results: A total of 451 patients were included within 48 hours of admission to the ICU. At 6 months of follow up, 159 patients had died and 40 patients were lost to follow up. When the general health item was used as an estimate of HRQOL, area under the curve for model A (0.719) was comparable to that of model C (0.721) and slightly better than that of model D (0.760). When PCS and MCS were used, the area under the curve for model B (0.736) was comparable to that of model C (0.721) and slightly better than that of model E (0.768). When using the general health item, the sensitivity and specificity in model D (sensitivity 0.52 and specificity 0.81) were similar to those in model A (0.45 and 0.80). Similar results were found when using the MCS and PCS.
Conclusion: This study shows that the pre-admission HRQOL measured with either the one-item general health question or the complete SF-36 is as good at predicting survival/mortality in ICU patients as the APACHE II score. The value of these measures in clinical practice is limited, although it seems sensible to incorporate assessment of HRQOL into the many variables considered when deciding whether a patient should be admitted to the ICU.

It is difficult for doctors to predict whether a critically ill patient will survive intensive care treatment. Mortality in patients admitted to intensive care units (ICU) remains high. An increasing number of in-hospital patients die in the ICU. The advantages of a validated strategy to identify those patients who will not benefit from ICU treatment are evident. Providing critical care treatment to patients who will ultimately die in the ICU is accompanied by an enormous emotional and physical burden for both patients and their relatives. Furthermore, ICU resources are scarce, and identifying those patients who will not survive intensive care treatment allows us to make better use of what resources are available. The available predicting tools, including the Acute Physiology and Chronic Health Evaluation (APACHE) II score, are based on a combination of pre-morbid factors and acute physiology items recorded during the first 24 hours after admission. The use of these systems in individual patients is limited because they have been validated at the group level. Consequently, ICU doctors must rely upon their clinical experience in their decision making. The predictive value of clinical experience in this regard is also limited. We hypothesized that the perceived health-related quality of life (HRQOL) of patients also reflects components of 'physiological reserve' and could, as such, act as a predictor of mortality.

The goal of the present study was to evaluate the predictive value for survival of the pre-admission HRQOL, alone and in combination with the APACHE II score, in critically ill patients.