The Pressure to Withhold or Withdraw Life-sustaining Therapy from Critically Ill Patients in the United States

Luce, John M.; White, Douglas B.

doi:10.1164/rccm.200609-1397cp

Cited by 60 publications

(43 citation statements)

References 39 publications

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“…With substantial uncertainty in prognosis and patient preferences for life support, more frequent provision of prolonged mechanical ventilation would be expected. (12,28,31,32) However, this default strategy was associated with unanticipated high mortality, profound and chronic disability, as well as significant financial stress and caregiving demands for families-the same poor outcomes that most adults with serious illness report that they would choose to avoid were they to understand the risk. (33) What can be done to help decision makers set reasonable goals for patient care as well as to plan for the unique needs of patients who subsequently transition from acute to chronic critical illness?…”

Section: Discussionmentioning

confidence: 99%

Expectations and outcomes of prolonged mechanical ventilation

Cox¹

2010

Critical Care Medicine

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Objective: Prolonged mechanical ventilation (PMV) provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the PMV decision making process could provide an explanation to this phenomenon. Therefore, we aimed to compare PMV decision makers' expectations for long-term patient outcomes with prospectively observed outcomes.Design, Setting, and Patients: 126 patients undergoing PMV, their surrogates, and their intensive care unit physicians were enrolled consecutively (total n=378) at an academic medical center between April 2006 and April 2007 and followed prospectively for one year. Measurements:Participants were interviewed at the time of tracheostomy placement about their expectations for one-year patient survival, functional status, and quality of life. These expectations were then compared to observed one-year outcomes measured with validated questionnaires.Results: One-year follow up was 100%, with the exception of patient death or cognitive inability to complete interviews. At one year, only 11 (9%) patients were alive and independent of major functional status limitations. Most surrogates reported high baseline expectations for one-year patient survival (117 [93%]), functional status (90 [71%]), and quality of life (105 [83%]). In contrast, fewer physicians described high expectations for survival (54 [43%]), functional status (7 [6%]), and quality of life (5 [4%]). Surrogate-physician pair concordance in expectations was poor (all κ<0.08), as was their accuracy in outcome prediction (range 23-44%). Just 33 (26%) surrogates reported that physicians discussed what to expect for patients' likely future survival, general health, and caregiving needs. Conclusions:One-year patient outcomes for PMV patients were significantly worse than expected by patients' surrogates and physicians. Lack of prognostication about outcomes, discordance between

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Section: Discussionmentioning

confidence: 99%

Expectations and outcomes of prolonged mechanical ventilation

Cox¹

2010

Critical Care Medicine

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“…(Critical Care Nurse. 2012;32 [3]: [14][15][16][17][18][19][20][21][22][23][24] nursing practice. In this article, I discuss the practical nursing aspects of managing an adult patient undergoing the withdrawal of mechanical ventilation as an end-of-life procedure.…”

Section: Cnecontinuing Nursing Educationmentioning

confidence: 99%

“…The patient and family should be given time to think about their decisions and discuss them with each other. 19 The patient's and/or family's prior experiences with withholding and/or withdrawing life-sustaining treatments may have a marked influence upon their ability to make a decision. It is important to know if they have had a previous experience, and if so, how they feel about it and what was the outcome of that experience.…”

Section: Dur Ing the Confer Encementioning

confidence: 99%

Withdrawal of Life-Sustaining Treatment

Stacy

2012

Critical Care Nurse

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Withdrawal of life support is an option for patients with prolonged mechanical ventilation when all attempts at weaning have failed and it is deemed futile to continue the therapy, when quality of life is unacceptable, or when it is perceived that the patient is suffering. The purpose of this article is to present the nursing aspects of managing an adult patient undergoing the withdrawal of mechanical ventilation as an end-of-life procedure. Withdrawal of mechanical ventilation is a complex and difficult process that requires meticulous planning and management. Conferences with the patient and the patient’s family are critical to addressing emotional support and ensuring that everyone understands the process and is provided an opportunity to gather information. Clear communication with patients and their families can ensure that the process goes smoothly. Having an organized approach can ensure that patients experience a peaceful death and staff experience closure regarding the event.

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“…This is in part highlighted by the vast body of literature on the topic, ranging from decision-making (Luce and White 2007) to bereavement (Schulz et al 2003) to evaluations of end-of-life care in hospitals (Chapple 2010).…”

Section: Introductionmentioning

confidence: 99%