Withdrawing Care

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Abstract
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 —Consecutive series of 28 patients in whom mechanical ventilation, dialysis, and/or vasopressors were withdrawn.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. (JAMA. 1994;271:1358-1361)