Determinants of Limiting Life-Sustaining Treatment in Critically Ill COVID-19 Patients: A Multicenter Study in Korean ICUs

Heo, I Re; Kim, Tae Hoon; Jung, Won Jai; Seong, Gil Myeong; Kwon, Sun Jung; Moon, Jae Young; Lee, Song-I; Moon, Do Sik; Kim, Tae-Ok; Park, Chul; Choi, Eun Young; Yoo, Jung-Wan; Park, Sunghoon; Baek, Ae Rin; Lim, Sung Yoon; Kim, Jung Soo; Lee, Jongmin; Chung, Chi Ryang; Lee, Sang-Min; Lee, Su Hwan; Baek, Moon Seong; Huh, Jin Won; Cho, Woo Hyun; Kim, Ho Cheol

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Original Article

DOI: https://doi.org/10.4046/trd.2024.0137 [Accepted]
Published online April 28, 2025.

Determinants of Limiting Life-Sustaining Treatment in Critically Ill COVID-19 Patients: A Multicenter Study in Korean ICUs

I Re Heo¹, Tae Hoon Kim¹, Won Jai Jung², Gil Myeong Seong³, Sun Jung Kwon⁴, Jae Young Moon⁵, Song-I Lee⁶, Do Sik Moon⁷, Tae-Ok Kim⁸, Chul Park⁹, Eun Young Choi¹⁰, Jung-Wan Yoo¹¹, Sunghoon Park¹², Ae Rin Baek¹³, Sung Yoon Lim¹⁴, Jung Soo Kim¹⁵, Jongmin Lee¹⁶, Chi Ryang Chung¹⁷, Sang-Min Lee¹⁸, Su Hwan Lee¹⁹, Moon Seong Baek²⁰, Jin Won Huh²¹, Woo Hyun Cho²², Ho Cheol Kim¹

¹Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
²Division of Pulmonary, Allergy, and Critical Care Medicine, Korea University Anam Hospital, Seoul, Korea
³Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
⁴Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Konyang University Hospital, Daejeon, Korea
⁵Department of Internal Medicine, Chungnam National University College of Medicine, Chungnam National University Sejong Hospital, Sejong, Korea
⁶Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University College of Medicine, Chungnam National University Hospital, Daejeon, Korea
⁷Department of Pulmonology and Critical Care Medicine, Chosun University Hospital, Gwangju, Korea
⁸Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
⁹Division of Pulmonology and Critical Care Medicine, Wonkwang University Hospital, Iksan, Korea
¹⁰Division of Pulmonology and Allergy, Department of Internal Medicine, College of Medicine, Yeungnam University and Regional Center for Respiratory Diseases, Yeungnam University Medical Center, Daegu, Korea
¹¹Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
¹²Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
¹³Division of Allergy and Pulmonary Medicine, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
¹⁴Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
¹⁵Division of Critical Care Medicine, Department of Hospital Medicine, Inha College of Medicine, Incheon, Korea
¹⁶Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
¹⁷Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
¹⁸Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
¹⁹Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
²⁰Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
²¹Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
²²Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Transplant Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea

Correspondence: Ho Cheol Kim, Tel: +82-55-214-3730, Fax: +82-55-214-8618,
Email: hockkim@gnu.ac.kr

Received: 20 September 2024 • Revised: 5 January 2025 • Accepted: 31 March 2025

Abstract

Background
Understanding life-sustaining treatment (LST) decisions in critically ill COVID-19 patients remains limited. This study aimed to identify factors influencing LST decisions and compare clinical outcomes between patients with and without LST.
Methods
This multicenter, retrospective cohort study analyzed data from 1,081 COVID-19 patients admitted to ICUs across Korea from January 1, 2020, to August 31, 2021. Patients were divided into LST and non-LST groups. Demographic, clinical, and outcome data were collected and compared.
Results
Of 1,081 patients, 207 (19.2%) received LST. LST patients were older (median age: 76 vs. 67 years, p < 0.001) and had more comorbidities (85.5% vs. 70.4%, p < 0.001), particularly cardiovascular and chronic lung disease. They had higher BUN, lower albumin, and elevated D-dimer levels (all p < 0.05). ICU interventions, including mechanical ventilation (82.6% vs. 50.9%, p < 0.001) and ECMO (18.8% vs. 9.8%, p < 0.001), were more common. ICU and hospital mortality rates were significantly higher in LST patients (82.6% and 94.2%, respectively, p < 0.001). Logistic regression identified age (OR = 1.054 per year, p < 0.001), mechanical ventilation (OR = 2.789, p = 0.002), and ECMO use (OR = 3.580, p = 0.002) as independent predictors of LST.
Conclusion
Age, comorbidities, and ICU interventions significantly influence LST decisions, highlighting the need for ethical and evidence-based critical care guidelines.

Key Words: COVID-19, Life-sustaining treatments, ICU, Mechanical ventilation, ECMO, Predictors, Retrospective cohort, Korea