Delicate Debate Urged Over Withdrawal of Life Support

FRIDAY Oct. 17, 2008 -- Almost half of the patients who die in the intensive care units of hospitals do so after a prolonged withdrawal of life support, a process doctors refer to as "stuttering," a new study found.

And even though families were often more satisfied after such a process, doctors feel this was frequently not in the best interest of the patient.

"This study suggests that the way we currently conduct withdrawal of life-sustaining treatments in the ICU is not consistent with what many of us feel ought to be the best approach," said study senior author Dr. J. Randall Curtis, a professor of medicine in the division of pulmonary and critical care medicine at the University of Washington School of Medicine. "This is a wake-up call to physicians working in the ICU to look critically at ways they think about this and do this."

One-fifth of all deaths in the United States occur during or soon after a stay in the intensive care unit, according to background information in the study. Yet there is little emphasis on palliative care in this setting, and dying in an ICU has often been described as "impersonal."

No previous research had addressed the timing of withdrawal of life support, particularly the sequence of the withdrawals.

"There really aren't specific guidelines for how to do this," said Dr. Roy Smythe, chairman of surgery at the Texas A&M Health Science Center College of Medicine.

"I think that most terminal patients, if given the choice, would not elect to have their care withdrawn in a stuttering fashion," added Smythe, who's also chairman of surgery at Scott & White Hospital in Temple.

The new study, published in October in the American Journal of Respiratory and Critical Care Medicine, involved talking to family members and examining medical charts of 584 patients who had died in an ICU (or soon after discharge) at one of 14 hospitals after withdrawal of life support.

Withdrawal took more than one day for almost half of the patients. These patients tended to be younger, had stayed longer in the ICU, had experienced more life-sustaining interventions, were less likely to have cancer, and had more people involved in decision-making. They were on four life-support systems, on average, in the days before their death, ranging from mechanical ventilation to feeding tubes, the study found.

Extubation (removing ventilator tubes) before death was linked with higher family satisfaction.

"My take on these data is that when life support is removed gradually, physicians don't bring families along -- they're not speaking to families enough as they're making the decisions," Curtis said. "Physicians often take several days to make up their own mind. Families need to be brought along, then it takes several more days. Withdrawing slowly gives the family time to catch up, but if they're involved earlier that wouldn't be necessary."

Smythe added: "If you look across past studies, one of the things that is always brought up is dissatisfaction with communication with physicians. My concern is that stuttering withdrawal of care is a surrogate for physicians not having good communication with patients... You'd be surprised, probably 80 percent of the time, if you're very clear about the consequences of not withdrawing care, families don't want that."

More information

Visit the U.S. National Cancer Institute for more on end-of-life issues.

Posted: October 2008


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