Increasing incidence of withholding and withdrawal of life support from the critically ill.

Abstract

To determine whether limits to life-sustaining care are becoming more common, we attempted to quantify the incidence of recommendations to withhold or withdraw life support from critically ill patients, to describe how patients respond to these recommendations, and to examine how conflicts over these recommendations are resolved. In 1992 and 1993 we prospectively enrolled 179 consecutive patients from two intensive care units (ICUs) for whom a recommendation was made to withhold or withdraw life support. Where possible, we compared results with data collected in the same units over a similar time period in 1987 and 1988. Recommendations to withhold or withdraw life support preceded 179 of 200 deaths (90%) in 1992 and 1993, compared with 114 of 224 deaths (51%) in 1987 and 1988 (chi2 = 73.76, p < 0.001]. Cardiopulmonary resuscitation was initiated in 10% of deaths in 1992 and 1993 as compared with 49% in 1987 and 1988. Ninety percent of patients agreed within less than 5 d, and only eight patients (4%) refused physicians' recommendations to limit life support. In cases of conflict, physicians in 1992 and 1993 deferred to patients with one exception: physicians were willing to refuse surrogate requests for resuscitation of patients they considered hopelessly ill. We conclude that 90% of patients who die in these ICUs now do so following a decision to limit therapy, that this represents a major change in practice in these institutions over a period of 5 yr, that most patients and surrogates accept an appropriate recommendation to withhold or withdraw life support, and that physicians will refuse surrogate requests in certain circumstances.

Changes in Medical Students’ Attitudes Towards End-of-Life Decisions Across Different Years of Medical Training

“…The views of year 5 medical students were in line with those of practicing clinicians documented in previous studies. 19,[21][22][23][24][25][26][27][28] These changes with the years of medical education suggest that the differences between medical and non-medical students are due to the medical school experience and not selection of people with intrinsically different views. The absence of an age-related effect in non-medical students suggests that these changes are not an age-related phenomenon but are related to the medical school experience.…”

Limitação de suporte de vida em três unidades de terapia intensiva pediátrica do sul do Brasil

“…1 Several studies have been published, especially in the USA, since 1990, that question the principle of life at any cost. 2,3 End-of-life decisions are now widely discussed, placing a high value on the respect for the patient, including a growing concern with maintaining dignity at the end of life and humanization of death. 4 Concomitantly, the concept of life support limitation (LSL), which includes do-notresuscitate orders, and withholding and withdrawal of life support, has appeared in medical practice to avoid the use of treatments that only prolong life but do not improve patient outcome, usually leading to useless treatments and needless suffering.…”

Increased nonbeneficial care in patients spending their birthday in the ICU

“…Over the last two decades, studies have identified substantial biases in the end-of-life decision-making process [9][10][11][12][13]. These biases may account for considerable practice differences that cannot be explained by routinely collected information.…”

“…Last, discrepancies have been reported across countries in the incidence of death after DFLSTs, characteristics of patients who die after DFLSTs, and weight given to the patient's and family's opinion [4,7,8]. In addition to cultural specificities, legislation may substantially affect practices regarding end-of-life decisions [2,12,16,[21][22][23].…”

“…End-of-life decisions were made in 22% and 24% of cases and controls, respectively. However, these decisions were made later in the cases than in the controls (18 versus 9 [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] days). Conclusions: Our finding that patients who spent their birthday in the ICU received a higher intensity of lifesustaining care and had longer ICU stays but did not have significantly different mortality rates compared with the controls suggests the use of nonbeneficial interventions.…”