{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T22:06:13Z","timestamp":1781647573778,"version":"3.54.5"},"reference-count":31,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2023,1,6]],"date-time":"2023-01-06T00:00:00Z","timestamp":1672963200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2023,1,6]],"date-time":"2023-01-06T00:00:00Z","timestamp":1672963200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Universit\u00e4tsklinikum D\u00fcsseldorf. Anstalt \u00f6ffentlichen Rechts"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Med Inform Decis Mak"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making.\n<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80\u00a0years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback\u2013Leibler divergence with regard to withholding or withdrawing decisions.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback\u2013Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required.<\/jats:p>\n                <jats:p><jats:italic>Trial registration<\/jats:italic>: VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12911-022-02094-z","type":"journal-article","created":{"date-parts":[[2023,1,6]],"date-time":"2023-01-06T15:05:01Z","timestamp":1673017501000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":22,"title":["Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care"],"prefix":"10.1186","volume":"23","clinical-trial-number":[{"clinical-trial-number":"nct03134807","registry":"10.18810\/clinical-trials-gov"},{"clinical-trial-number":"nct03370692","registry":"10.18810\/clinical-trials-gov"}],"author":[{"given":"Michael","family":"Beil","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"P. Vernon","family":"van Heerden","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dylan W.","family":"de Lange","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wojciech","family":"Szczeklik","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susannah","family":"Leaver","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bertrand","family":"Guidet","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hans","family":"Flaatten","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian","family":"Jung","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sigal","family":"Sviri","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leo","family":"Joskowicz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2023,1,6]]},"reference":[{"key":"2094_CR1","doi-asserted-by":"publisher","first-page":"1769","DOI":"10.1097\/CCM.0000000000001965","volume":"44","author":"AA Kon","year":"2016","unstructured":"Kon AA, Shepard EK, Sederstrom NO, Swoboda SM, Marshall MF, Birriel B, Rincon F. Defining futile and potentially inappropriate interventions. Crit Care Med. 2016;44:1769\u201374.","journal-title":"Crit Care Med"},{"key":"2094_CR2","doi-asserted-by":"publisher","first-page":"1319","DOI":"10.1007\/s00134-017-4718-z","volume":"43","author":"H Flaatten","year":"2017","unstructured":"Flaatten H, de Lange DW, Artigas A, Bin D, Moreno R, Christensen S, Joynt GM, Bagshaw SM, Sprung CL, Benoit D, Soares M, Guidet B. The status of intensive care medicine research and a future agenda for very old patients in the ICU. Intensive Care Med. 2017;43:1319\u201328.","journal-title":"Intensive Care Med"},{"key":"2094_CR3","doi-asserted-by":"publisher","first-page":"1027","DOI":"10.1007\/s00134-018-5196-7","volume":"44","author":"B Guidet","year":"2018","unstructured":"Guidet B, Flaatten H, Boumendil A, Morandi A, Andersen F, Artigas A, Bertolini G, Cecconi M, Christensen S, Feraldi L, Fj\u00f6lner J, Jung C, Marsh B, Moreno R, Bollen Pinto B, Szczeklik W, Valentin A, Watson X, Zaferidis T, De Lange D. Withholding or withdrawing of life sustaining therapy in very elderly patients (\u2265 80 years) admitted to the intensive care unit. Intensive Care Med. 2018;44:1027\u201338.","journal-title":"Intensive Care Med"},{"key":"2094_CR4","doi-asserted-by":"publisher","first-page":"474","DOI":"10.1097\/CCM.0b013e318205df9b","volume":"39","author":"W Meadow","year":"2011","unstructured":"Meadow W, Pohlman A, Frain L, Ren Y, Kress JP, Teuteberg W, Hall J. Power and limitations of daily prognostications of death in the medical intensive care unit. Crit Care Med. 2011;39:474\u20139.","journal-title":"Crit Care Med"},{"key":"2094_CR5","doi-asserted-by":"publisher","first-page":"34","DOI":"10.1016\/j.jcrc.2020.10.006","volume":"61","author":"M Beil","year":"2021","unstructured":"Beil M, Sviri S, Flaatten H, De Lange DW, Jung C, Szczeklik W, Leaver S, Rhodes A, Guidet B, van Heerden PV. On predictions in critical care: the individual prognostication fallacy in elderly patients. J Crit Care. 2021;61:34\u20138.","journal-title":"J Crit Care"},{"key":"2094_CR6","doi-asserted-by":"publisher","first-page":"523","DOI":"10.1001\/jamainternmed.2014.7889","volume":"175","author":"LE Ferrante","year":"2015","unstructured":"Ferrante LE, Pisani MA, Murphy TE, Gahbauer EA, Leo-Summers LS, Gill TM. Functional trajectories among older persons before and after critical illness. JAMA Intern Med. 2015;175:523\u20139.","journal-title":"JAMA Intern Med"},{"key":"2094_CR7","doi-asserted-by":"publisher","first-page":"330","DOI":"10.1186\/s13054-020-03017-y","volume":"24","author":"MC Kerckhoffs","year":"2020","unstructured":"Kerckhoffs MC, Brinkman S, de Keizer N, Soliman IW, de Lange DW, van Delden JJM, van Dijk D. The performance of acute versus antecedent patient characteristics for 1-year mortality prediction during intensive care unit admission. Crit Care. 2020;24:330.","journal-title":"Crit Care"},{"key":"2094_CR8","doi-asserted-by":"publisher","first-page":"324","DOI":"10.1097\/CCM.0000000000004772","volume":"49","author":"H Vallet","year":"2021","unstructured":"Vallet H, Schwarz GL, Flaatten H, de Lange DW, Guidet B, Dechartres A. Mortality of older patients admitted to an intensive care unit a systematic review. Crit Care Med. 2021;49:324\u201334.","journal-title":"Crit Care Med"},{"key":"2094_CR9","doi-asserted-by":"publisher","first-page":"117","DOI":"10.1186\/s12877-016-0292-4","volume":"16","author":"KJ Gregorevic","year":"2016","unstructured":"Gregorevic KJ, Hubbard RE, Lim WK, Katz B. The clinical frailty scale predicts functional decline and mortality when used by junior medical staff: a prospective cohort study. BMC Geriatr. 2016;16:117.","journal-title":"BMC Geriatr"},{"key":"2094_CR10","doi-asserted-by":"publisher","first-page":"57","DOI":"10.1007\/s00134-019-05853-1","volume":"46","author":"B Guidet","year":"2020","unstructured":"Guidet B, de Lange DW, Boumendil A, Leaver S, Watson X, Boulanger C, et al. The contribution of frailty, cognition, activity of daily life and comorbidities on outcome in acutely admitted patients over 80 years in European ICUs: the VIP2 study. Intensive Care Med. 2020;46:57\u201369.","journal-title":"Intensive Care Med"},{"key":"2094_CR11","doi-asserted-by":"publisher","first-page":"1572","DOI":"10.1007\/s00134-015-3810-5","volume":"41","author":"NM Mark","year":"2015","unstructured":"Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit. Intensive Care Med. 2015;41:1572\u201385.","journal-title":"Intensive Care Med"},{"key":"2094_CR12","doi-asserted-by":"publisher","first-page":"122","DOI":"10.1080\/00140139.2017.1301573","volume":"61","author":"TW Reader","year":"2018","unstructured":"Reader TW, Reddy G, Brett SJ. Impossible decision? An investigation of risk trade-offs in the intensive care unit. Ergonomics. 2018;61:122\u201333.","journal-title":"Ergonomics"},{"key":"2094_CR13","doi-asserted-by":"publisher","first-page":"1128","DOI":"10.1007\/s00134-013-2871-6","volume":"39","author":"DJC Wilkinson","year":"2013","unstructured":"Wilkinson DJC, Truog RD. The luck of the draw: physician-related variability in end-of-life decision-making in intensive care. Intensive Care Med. 2013;39:1128\u201332.","journal-title":"Intensive Care Med"},{"key":"2094_CR14","doi-asserted-by":"publisher","first-page":"421","DOI":"10.1136\/medethics-2020-106332","volume":"46","author":"K Liddell","year":"2020","unstructured":"Liddell K, Skopek JM, Palmer S, Martin S, Anderson J, Sagar A. Who gets the ventilator? Important legal rights in a pandemic. J Med Ethics. 2020;46:421\u20136.","journal-title":"J Med Ethics"},{"key":"2094_CR15","doi-asserted-by":"crossref","unstructured":"Shannon CE, Sloane NJA, Wyner AD. Claude Elwood Shannon: Collected Papers. IEEE Press; 1993. ISBN:978-0-7803-0434-5.","DOI":"10.1109\/9780470544242"},{"key":"2094_CR16","doi-asserted-by":"crossref","unstructured":"Flaatten H, De Lange DW, Morandi A, Andersen FH, Artigas A, Bertolini G, Boumendil A, Cecconi M, Christensen S, Faraldi L, Fj\u00f8lner J, Jung C, Marsh B, Moreno R, Oeyen S, \u00d6hman CA, Pinto BB, Soliman IW, Szczeklik W, Valentin A, Watson X, Zaferidis T, Guidet B; VIP1 study group. The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (\u2265 80 years). Intensive Care Med. 2017;43:1820\u20138.","DOI":"10.1007\/s00134-017-4940-8"},{"key":"2094_CR17","doi-asserted-by":"publisher","first-page":"334","DOI":"10.1126\/science.1227946","volume":"338","author":"MD Brennan","year":"2012","unstructured":"Brennan MD, Cheong R, Levchenko A. How information theory handles cell signaling and uncertainty. Science. 2012;338:334\u20135.","journal-title":"Science"},{"key":"2094_CR18","doi-asserted-by":"publisher","first-page":"254","DOI":"10.5770\/cgj.23.463","volume":"23","author":"K Rockwood","year":"2020","unstructured":"Rockwood K, Theou O. Using the clinical frailty scale in allocating scarce health care resources. Can Geriatr J. 2020;23:254\u20139.","journal-title":"Can Geriatr J"},{"key":"2094_CR19","doi-asserted-by":"publisher","first-page":"1793","DOI":"10.1097\/00003246-199811000-00016","volume":"26","author":"JL Vincent","year":"1998","unstructured":"Vincent JL, de Mendonca A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S. Use of the SOFA score to assess the incidence of organ dysfunction\/failure in intensive care units. Crit Care Med. 1998;26:1793\u2013800.","journal-title":"Crit Care Med"},{"key":"2094_CR20","doi-asserted-by":"publisher","first-page":"11865","DOI":"10.1038\/srep11865","volume":"5","author":"D Dahlem","year":"2015","unstructured":"Dahlem D, Maniloff D, Ratti C. Predictability bounds of electronic health records. Sci Rep. 2015;5:11865.","journal-title":"Sci Rep"},{"key":"2094_CR21","doi-asserted-by":"publisher","first-page":"722","DOI":"10.1136\/medethics-2020-106330","volume":"47","author":"J Cameron","year":"2021","unstructured":"Cameron J, Savulescu J, Wilkinson D. Is withdrawing treatment really more problematic than withholding treatment? J Med Ethics. 2021;47:722\u20136.","journal-title":"J Med Ethics"},{"key":"2094_CR22","doi-asserted-by":"publisher","first-page":"321","DOI":"10.1016\/j.chest.2017.04.176","volume":"152","author":"SM Lobo","year":"2017","unstructured":"Lobo SM, De Simoni FHB, Jakob SM, Estella A, Vadi S, Bluethgen A, Martin-Loeches I, Sakr Y, Vincent JL. Decision-making on withholding or withdrawing life support in the ICU: a worldwide perspective. Chest. 2017;152:321\u20139.","journal-title":"Chest"},{"key":"2094_CR23","doi-asserted-by":"publisher","first-page":"1123","DOI":"10.1056\/NEJMoa030083","volume":"349","author":"D Cook","year":"2003","unstructured":"Cook D, Rocker G, Marshall J, Sjokvist P, Dodek P, Griffith L, Freitag A, Varon J, Bradley C, Levy M, Finfer S, Hamielec C, McMullin J, Weaver B, Walter S, Guyatt G. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med. 2003;349:1123\u201332.","journal-title":"N Engl J Med"},{"key":"2094_CR24","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1093\/ageing\/afaa171","volume":"50","author":"EG Lewis","year":"2021","unstructured":"Lewis EG, Breckons M, Lee RP, Dotchin C, Walker R. Rationing care by frailty during the COVID-19 pandemic. Age Ageing. 2021;50:7\u201310.","journal-title":"Age Ageing"},{"key":"2094_CR25","doi-asserted-by":"publisher","first-page":"20","DOI":"10.1038\/s42256-018-0004-1","volume":"1","author":"E Begoli","year":"2019","unstructured":"Begoli E, Bhattacharya T, Kusnezov D. The need for uncertainty quantification in machine-assisted medical decision making. Nat Mach Intell. 2019;1:20\u20133.","journal-title":"Nat Mach Intell"},{"key":"2094_CR26","doi-asserted-by":"publisher","first-page":"1522","DOI":"10.1097\/CCM.0000000000003903","volume":"47","author":"CR Bassford","year":"2019","unstructured":"Bassford CR, Krucien N, Ryan M, Griffiths FE, Svantesson M, Fritz Z, Perkins GD, Quinton S, Slowther AMUK. Intensivists\u2019 preferences for patient admission to ICU: evidence from a choice experiment. Crit Care Med. 2019;47:1522\u201330.","journal-title":"Crit Care Med"},{"key":"2094_CR27","doi-asserted-by":"publisher","first-page":"99","DOI":"10.1016\/j.jcrc.2018.11.027","volume":"50","author":"PD Gopalan","year":"2019","unstructured":"Gopalan PD, Pershad S. Decision-making in ICU\u2014a systematic review of factors considered important by ICU clinician decision makers with regard to ICU triage decisions. J Crit Care. 2019;50:99\u2013110.","journal-title":"J Crit Care"},{"key":"2094_CR28","doi-asserted-by":"publisher","first-page":"291","DOI":"10.1186\/s13054-018-2203-x","volume":"22","author":"CM Martin","year":"2018","unstructured":"Martin CM. Is access to intensive care equitable? Crit Care. 2018;22:291.","journal-title":"Crit Care"},{"key":"2094_CR29","doi-asserted-by":"publisher","first-page":"958","DOI":"10.1164\/rccm.201701-0165CP","volume":"196","author":"AJ Walkey","year":"2017","unstructured":"Walkey AJ, Barnato AE, Wiener RS, Nallamothu BK. Accounting for patient preferences regarding life-sustaining treatment in evaluations of medical effectiveness and quality. Am J Respir Crit Care Med. 2017;196:958\u201363.","journal-title":"Am J Respir Crit Care Med"},{"key":"2094_CR30","doi-asserted-by":"publisher","first-page":"55","DOI":"10.7326\/M14-0697","volume":"162","author":"GS Collins","year":"2015","unstructured":"Collins GS, Reitsma JB, Altman DG, Moons KG. Transparent Reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. Ann Intern Med. 2015;162:55\u201363.","journal-title":"Ann Intern Med"},{"key":"2094_CR31","doi-asserted-by":"publisher","DOI":"10.1145\/3368555.3384457","author":"MW Dusenberry","year":"2020","unstructured":"Dusenberry MW, Tran D, Choi E, Kemp J, Nixon J, Jerfel G, Heller K, Dai AM. Analyzing the role of model uncertainty for electronic health records. Proc ACM Conf Health Inference Learn. 2020. https:\/\/doi.org\/10.1145\/3368555.3384457.","journal-title":"Proc ACM Conf Health Inference Learn"}],"container-title":["BMC Medical Informatics and Decision Making"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12911-022-02094-z.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12911-022-02094-z\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12911-022-02094-z.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,1,6]],"date-time":"2023-01-06T15:06:54Z","timestamp":1673017614000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcmedinformdecismak.biomedcentral.com\/articles\/10.1186\/s12911-022-02094-z"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,1,6]]},"references-count":31,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2023,12]]}},"alternative-id":["2094"],"URL":"https:\/\/doi.org\/10.1186\/s12911-022-02094-z","relation":{},"ISSN":["1472-6947"],"issn-type":[{"value":"1472-6947","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,1,6]]},"assertion":[{"value":"30 March 2021","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"23 December 2022","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"6 January 2023","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Ethics approval for the observational studies was granted by the National Regional Board in Helse S\u00f8r-\u00d8st in Norway (reference numbers for VIP1: 2016\/806\/REK and VIP2: 2018\/87\/REK). That included permission to access data. Then, each participating country in VIP1 and VIP2 had a national coordinator responsible for national or regional ethical and regulatory study approval [, ]. This included ethics committees which waived the need for informed consent, such as in Poland (Jagiellonian University Krakow, reference number: 122.6120.270.2016), Austria (Medical University Innsbruck, reference number: 1225\/2018) and Norway (see above). All methods were carried out in accordance with relevant guidelines and regulations.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"All authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"1"}}