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Publications

Journal Article Ahead of print

PubMed: 42316265 DOI: 10.1186/s13054-026-06139-x

Timing matters: sex differences in treatment limitation decisions in intensive care.

Crit Care

Authors: Simon A Amacher, Pimrapat Gebert, Valentina Tröster, Nidaa Mikail, Adriana Vinzens, Vera Regitz-Zagrosek, Ketina Arslani, Julie Helms, Hamid Merdji, Micah T Long, Sabina Hunziker, Martin Lohri, Pascale Grzonka, Sebastian Berger, Alexa Hollinger, Karin Wildi, Bernd Yuen, Mark Kaufmann, Raoul Sutter, Martin Siegemund, Catherine Gebhard, Caroline E Gebhard

Affiliations

  • Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland.
  • Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center University of Freiburg, University of Freiburg, Freiburg, Germany.
  • Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
  • Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.
  • Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland.
  • Institute of Gender in Medicine (GiM), Charité - Universitätsmedizin Berlin, Berlin, Germany.
  • Department of Cardiology, University Hospital Basel, Basel, Switzerland.
  • Faculté de Médecine, Service de Médecine Intensive-Réanimation, Université de Strasbourg (UNISTRA), Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France.
  • INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
  • Department of Anesthesiology and Critical Care, University of Wisconsin Hospitals and Clinics, Madison, USA.
  • Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland.
  • University of Basel, Basel, Switzerland.
  • Anesthesiology, University Hospital Basel, Basel, Switzerland.
  • Interdepartmental Division of Critical Care, University Health Network, Toronto, Canada.
  • Intensive Care Unit, Cantonal Hospital Aarau, Aarau, Switzerland.
  • Intensive Care Unit, Stadtspital Zürich Triemli, Zurich, Switzerland.
  • Department of Neurology, University Hospital Basel, Basel, Switzerland.
  • Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland.
  • Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland.
  • University of Basel, Basel, Switzerland.
  • Intensive Care Unit, Stadtspital Zürich Triemli, Zurich, Switzerland.

Abstract

BACKGROUND

Sex differences in intensive care treatment and mortality are well documented, but the timing of decisions to limit treatment remains unclear. We investigated whether sex differences in decisions to limit treatment arise at ICU admission or during the ICU stay.

METHODS

Nationwide cohort study using the Swiss Minimal Dataset for Intensive Care Units, including adult (≥ 18 years) ICU admissions between 2016 and 2024. Two adjusted logistic regression models assessed treatment limitations documented at ICU admission and those occurring later among patients admitted without limitations.

RESULTS

Among 654,660 ICU stays, treatment limitations at admission were more common in women than men (12.0% vs. 8.6%), whereas rates during the ICU stay were similar (5.5% vs. 5.5%). Female sex was independently associated with limitations at admission (aOR 1.26, 95% CI 1.24-1.28) but only weakly associated with later limitations (aOR 1.10, 95% CI 1.08-1.13). Differences at admission varied by diagnosis and were most pronounced in trauma and cardiovascular conditions. Women more often had ceiling-of-care decisions and documented patient wishes, whereas men more frequently underwent withdrawal of life-sustaining therapies and physician-driven decisions. Mortality was highest with limitations at ICU admission and lowest without limitations, with minimal sex differences within categories.

CONCLUSIONS

In Switzerland, sex differences in treatment limitations occur mainly at ICU admission and vary across diagnoses. These findings suggest that differences may reflect early triage heuristics, societal norms influencing advance care planning, and potential implicit biases under prognostic uncertainty. Structured goal-of-care discussions at ICU admission may help promote consistent and equitable decision-making.

MeSH

Sex Characteristics, Sex, Diagnosis, Therapeutics, Intensive Care Units, Sex Differences