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

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.