Life support for patients without a surrogate decision maker: who decides?

Area of Science:

• Medical Ethics
• Critical Care Medicine
• Health Policy

Background:

• Life support withdrawal decisions are complex for incapacitated patients lacking surrogate decision-makers or advance directives.
• Little is known about the frequency and circumstances of these decisions in intensive care units (ICUs).

Purpose of the Study:

• To determine the proportion of ICU deaths in patients without decision-making capacity and a surrogate.
• To investigate the decision-making process employed by physicians in such cases.

Main Methods:

• A multicenter, prospective cohort study was conducted across 7 medical centers.
• Data were collected from 3011 critically ill adults between 2004 and 2005.
• Physicians completed questionnaires regarding decisions for incapacitated patients without surrogates.

Main Results:

• 5.5% of ICU deaths occurred in incapacitated patients lacking surrogates or advance directives, with significant center-to-center variability (0%-27%).
• Life support limitation was considered for 37 such patients; decisions were made by ICU teams or attending physicians in most cases (30/37).
• Few decisions involved prospective hospital (6/37) or court review (1/37), and many decisions (36/37) were inconsistent with American College of Physicians guidelines.

Conclusions:

• Incapacitated patients without surrogates represent about 1 in 20 ICU deaths.
• Physician-led decision-making for life support in these patients often occurs without formal institutional or judicial oversight.
• Variability in hospital policies, guidelines, and laws complicates decision-making for this vulnerable patient group.