Withdrawing Care

Abstract

<h3>Objective.</h3> —To describe the process and outcomes of withdrawing life-sustaining interventions in a medical intensive care unit (MICU). <h3>Design.</h3> —Retrospective case series. <h3>Setting.</h3> —Medical intensive care unit in a community teaching hospital. <h3>Patients.</h3> —Consecutive series of 28 patients in whom mechanical ventilation, dialysis, and/or vasopressors were withdrawn.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. <h3>Main Outcome Measures.</h3> —Duration of discussions, MICU length of stay, and hospital survival. <h3>Results.</h3> —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. <h3>Conclusions.</h3> —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. (<i>JAMA</i>. 1994;271:1358-1361)