Factors associated with withholding of invasive mechanical ventilation in the early phase of the COVID-19 response and their ethical analyses

Morioka S, Takashima K, Asai Y, Suzuki T, Nomoto H, Saito S, Suzuki K, Suzuki S, Sato L, Nakamura K, Nikaido M, Matsunaga N, Hayakawa K, Mori M, Yamamoto K, Ohmagari N

End-of-life decision making regarding invasive mechanical ventilation (IMV) for patients with severe coronavirus disease (COVID-19) is challenging. We aimed to explore the factors associated with the withholding of IMV in patients with COVID-19. This retrospective study included patients registered in a nationwide COVID-19 Registry Japan. We enrolled patients with COVID-19 admitted between January 1, 2020, and June 30, 2021, and died during hospitalization. The enrolled patients were divided into two groups: those who received IMV (IMV group) and those who did not (non-IMV group). To identify the factors associated with withholding of IMV among patients with COVID-19 who died during hospitalization, we conducted a multivariate logistic regression analysis. A total of 2,401 patients were enrolled. Of these, 588 (24.5%) were in the IMV group and 1813 (75.5%) in the non-IMV group. Withholding IMV was positively associated with older age (95% confidence interval [CI]: 0.82–0.88, p < 0.0001), dementia (95% CI: 0.81–0.91, p < 0.0001), chronic lung disease (95% CI: 0.88–1.00, p = 0.036), and malignancy (95% CI: 0.82–0.94, p < 0.0004) although inversely associated with male sex (95% CI: 1.04–1.15, p = 0.0008), body mass index (95% CI: 1.01–1.02, p < 0.0001), and National Early Warning Score (95% CI: 1.01–1.03, p < 0.0001). We subsequently analyzed these results to inform preparedness for future emerging infectious disease pandemics by retrospectively examining the decision-making processes during the COVID-19 crisis, with particular attention to the role of multidisciplinary collaboration. Based on this study, it will be essential in future pandemics to assess decisions concerning life-sustaining treatments, including IMV, from both scientific and ethical perspectives.

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