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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Consecutive series of 28 patients in whom mechanical ventilation, dialysis, and/or vasopressors were withdrawn.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.