Related Experiment Videos
Withdrawing care. Experience in a medical intensive care unit
D K Lee1, A J Swinburne, A J Fedullo
1Rochester General Hospital, NY 14621.
Objective:
To describe the process and outcomes of withdrawing life-sustaining interventions in a medical intensive care unit (MICU).
Design:
Retrospective case series.
Setting:
Medical intensive care unit in a community teaching hospital.
Patients:
Consecutive series of 28 patients in whom mechanical ventilation, dialysis, and/or vasopressors were withdrawn. We distinguished physiological, neurological, and functional rationales for care withdrawal.
Main Outcome Measures:
Duration of discussions, MICU length of stay, and hospital survival.
Results:
Mean +/- SD Acute Physiology and Chronic Health Evaluation (APACHE II) score was 27.1 +/- 7.3 on MICU admission, and average +/- SD predicted hospital mortality was 61% +/- 22%. Discussions leading to withdrawal of care occurred over an average +/- SD of 5.2 +/- 5.5 days, with decisions achieved soonest in cases with poor neurological prognosis. Average +/- SD MICU length of stay was 1.4 +/- 1.8 days following a decision to withdraw MICU care, and only four patients received more than 48 hours of additional MICU care. Four patients were discharged alive from the hospital.
Conclusions:
Patients and their surrogates willingly considered outcomes in addition to mortality when considering withdrawal of life-sustaining interventions. Finding an accommodation between physician judgments and patient preferences took time and effort but was an effective means of limiting ineffective life-sustaining efforts. Withdrawing futile or unwanted care was not always fatal.
Insights
Withdrawing life-sustaining treatments involved patient preferences beyond mortality, taking time to align physician and family decisions. This process effectively limited futile care, with some patients surviving withdrawal.
Area of Science:
- Critical Care Medicine
- Medical Ethics
- Palliative Care
Background:
- Withdrawing life-sustaining interventions is a complex process in intensive care.
- Understanding patient and surrogate decision-making is crucial.
Purpose of the Study:
- To describe the process and outcomes of withdrawing life-sustaining interventions in a medical intensive care unit (MICU).
Main Methods:
- Retrospective case series of 28 patients in a community teaching hospital's MICU.
- Analysis of mechanical ventilation, dialysis, and vasopressor withdrawal based on physiological, neurological, and functional rationales.
- Evaluation of discussion duration, MICU length of stay, and hospital survival.
Main Results:
- Patients had high APACHE II scores and predicted mortality (61%).
- Discussions averaged 5.2 days, decisions were faster with poor neurological prognosis.
- MICU length of stay post-decision was short (1.4 days), with 4 patients surviving to discharge.
Conclusions:
- Patient surrogates considered outcomes beyond mortality.
- Aligning physician and patient preferences required time and effort.
- Withdrawing futile or unwanted care did not always result in death.