Mortality in the coronary intensive care unit and approach to end-of-life care

Understanding and critically examining mortality in the coronary intensive care unit (CICU) is essential to ensure high-quality care. With advancements in healthcare technology, people are living longer, posing new challenges, particularly in defining the limits of medical intervention and recognizing when a situation is irreversible, with a shift needed toward comfort-focused care.

This study aimed to analyze four-year trends in mortality in the CICU, focusing on epidemiology, sociodemographic characteristics, causes of death, and end-of-life care practices.

We conducted a single-center, retrospective study of patients admitted between January 2021 and October 2024. Electronic medical records were reviewed and clinical variables of patients who died during their stay were collected. End-of-life care decisions were identified based on explicit documentation by physicians in the clinical notes.

During the study period, 3431 patients were admitted, and 89 deaths occurred (2.6%); 28 (31.5%) being females; of these, 31 (34.8%) happened within the first 24 hours of CICU admission. The average age was 75.3 ± 11.2 years old (range: 39-95 years), and the mean length of stay was 6.7 ± 10 days (range: 0–61 days). The highest mortality year was 2023, while 2024 recorded the lowest. Acute coronary syndrome (n=52, 58.4%) was the leading cause of admission, followed by heart failure (n=24, 27.0%). Mortality was directly related to the reason for admission in 86 cases (96.6%). Documented decisions on non-resuscitation, therapeutic ceiling, or treatment withdrawal were made in 32 cases (36.0%), with these decisions occurring an average of 10.4 ± 14.0 days after admission. Death occurred an average of 1.4 ± 1.4 days post-decision. The palliative care team was involved in 5 cases (5.6%), with these patients having a mean age of 73.4 ± 10.0 years (range: 59–87) and an average stay of 16.0 ± 17.1 days (range: 3–45 days). Among these, three patients had advanced heart failure, one had acute coronary syndrome, and one had infective endocarditis. In each case, palliative care played a crucial role in managing sedoanalgesia and facilitating communication with the family.

Mortality analysis revealed two primary death patterns in the CICU: death associated with acute coronary syndrome and terminal heart failure. Our data indicate that treatment limitation decisions are made for a small proportion of patients, a trend that has remained stable over the years. However, there is an upward trend in patients receiving sedoanalgesia during their final hours, suggesting increasing sensitivity among physicians toward addressing human suffering. Decisions regarding non-resuscitation, treatment limitation, and withdrawal are essential to prevent therapeutic overreach and futile prolongation of life, and these considerations should be reviewed daily for all CICU patients, especially the most critically ill.