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Original article

Vol. 155 No. 12 (2025)

Limitation of therapeutic efforts in internal medicine: a retrospective analysis of evolution and determinants (2013–2023) in a Swiss university hospital

Cite this as:
Swiss Med Wkly. 2025;155:4477
Published
23.12.2025

Summary

BACKGROUND/AIMS: In-hospital goals of care documentation is crucial for determining the adequate level of care in case of life-threatening emergencies. They might include limitation of therapeutic efforts, such as Do Not Resuscitate, Do Not Admit to intensive care unit (ICU) and Do Not Admit to intermediate care unit (IMCU) orders, or a “comfort care only” instruction. An ethical recommendation has recently been published to guide Do Not Resuscitate decisions, and several studies have shown a poor prognosis of frail multimorbid patients in case of critical illness. However, little is known on the use of limitation of therapeutic efforts other than Do Not Resuscitate in a hospital internal medicine population. We evaluated the evolution and determinants of the limitations of therapeutic efforts Do Not Resuscitate, Do Not Admit to ICU and Do Not Admit to IMCU between January 2013 and July 2023.

MATERIALS AND METHODS: We conducted a retrospective observational study in a Swiss university hospital internal medicine service. Overall, 51,569 hospital stays (28,273 patients) were included. We assessed the yearly prevalence of the different limitations of therapeutic efforts and searched for the determinants of each limitation of therapeutic effort through multivariable analysis with adjustments for year of hospitalisation, age, sex, religion, co-diagnoses, hospital length of stay, ICU or IMCU admission.

RESULTS: The prevalence of Do Not Resuscitate, Do Not Admit to ICU and Do Not Admit to IMCU increased between 2013 and 2023 from 47.5%, 4.5% and 0.8%, respectively, to 58%, 31.4% and 14.6%. In multivariable analysis, the main factor associated with limitation of therapeutic efforts overall was older age, with odds ratios and 95% confidence intervals of 406 (329–501) (Do Not Resuscitate), 8.98 (7.93–10.2) (Do Not Admit to ICU) and 7.52 (6.25–9.05) (Do Not Admit to IMCU) for the >85 relative to the 56–65 year subgroup. The comorbidities most associated with limitation of therapeutic efforts were metastatic cancer and dementia: 7.59 (6.54–8.82) and 5.49 (4.74–6.37), respectively, for Do Not Resuscitate; 2.19 (1.96–2.45) and 1.72 (1.59–1.87) for Do Not Admit to ICU; and 2.13 (1.81–2.50) and 2.10 (1.89–2.34) for Do Not Admit to IMCU. Male sex was associated with lower limitation of therapeutic efforts: 0.66 (0.61–0.72) for Do Not Resuscitate, 0.83 (0.79–0.88) for Do Not Admit to ICU and 0.84 (0.77–0.92) for Do Not Admit to IMCU.

CONCLUSION: The prevalence of limitation of therapeutic efforts in hospitalised medicine patients of our hospital increased during the past decade, with a remarkably large increase in limitation of admission to ICU (7-fold increase) and IMCU (18-fold increase). The main determinants of limitation of therapeutic efforts are older age, metastatic cancer and dementia. Reasons for the lower prevalence of limitation of therapeutic efforts in males should be explored. 

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