End of Life Decisions: Communicating With Care
Mechanical ventilation (being on a respirator) is the single most common form of advanced life support used in intensive care units (ICUs) in the US. But, deciding when to remove a patient from life support when it is clear that the patient will die soon thereafter, is often a challenging decision for physicians and a heart-wrenching one for families.
But what are the primary factors influencing physicians’ decisions to recommend withdrawing life support to a patient’s family?
Recently, a group of researchers set out to answer this question. The researchers anticipated that the patient’s age, wishes, and severity of illness, would be the criteria used to make this difficult decision. The results of the study, however, published in the September 18, 2003 issue of the New England Journal of Medicine , were surprising. Although the study did show that the physician’s perception of the patient’s wishes did factor prominently in their decision to withdraw life support, other factors such as the patient’s likelihood of survival, level of cognitive function, and need for certain medications, carried more weight than the patient’s age or severity of illness alone.
About the study
The researchers followed 851 adult patients in the ICU who needed a respirator and were expected to be in the ICU for at least 72 hours. They examined the relationship between a number of factors and the decision to withdraw life support: each patient’s base-line physiologic characteristics, level of organ function, decision-making ability, the type of life support administered, use of do-not-resuscitate orders (DNRs), as well as the patients’ prognoses and the physician’s perceptions of the patients’ preferences regarding the use of life support.
The physicians also documented which patients were successfully weaned from their respirators and which died either during or shortly after the withdrawal of the respirator.
Of the 851 patients included in the study, 539 (63.3%) were successfully weaned from their respirators. Another 146 (17.2%) died while on their respirators, and 166 (19.5%) had their respirators withdrawn in anticipation of their deaths. The researchers found that the individual factors most commonly taken into consideration when deciding when and whether to withdraw life support were the:
- need or use of inotropes or vasopressors (medications designed to help the blood circulate more efficiently and prevent the patient from going into shock)
- physician’s prediction that the patient’s likelihood of survival was less than 10%
- physician’s prediction that future cognitive function would be severely impaired
- physician’s perception that the patient did not want life support used
All of the factors, with the exception of the first, require a largely subjective judgment call on the part of the physician.
How does this affect you?
In this study, age and specific organ dysfunction were not the primary factors influencing a physician’s decision to withdraw life support from a critically ill patient. And although the use of medications to raise blood pressure and poor prognosis regarding survival indirectly imply a serious illness, physicians did not cite severity of the illness per se as a criterion. Importantly, the physicians’ perception of the patients’ wishes and their prediction of a high likelihood of poor cognitive function were key factors in their recommendations to the family.
This study highlights two important aspects of end of life decisions. First, it reflects a change in attitude and behavior on the part of physicians. Second, it highlights the potentially large influence a physician’s perceptions and communication skills can have on a family’s decision to withdraw life support from its loved one.
Thirty years ago, there were fewer technological measures a physician could take to prolong a patient’s life. However, there was also usually a stronger personal relationship among the physician, the patient, and the patient’s family. This allowed physician’s to take the lead in determining when and whether to remove a patient from life support because they were often already aware of what the patient’s wishes would be.
Now, physicians often find themselves involved in end of life decisions with patients and families with whom they often have no previous relationship, and while physician’s still take an active role in the process, the final decision lies firmly with the patient’s family. Therefore, physicians must be aware that because three of the four primary factors influencing their decision are subjective, the way they present this information to the family may have considerable influence over the decision the family makes. This is something all family members entrusted to make this ultimate decision need to know.
Society of Critical Care Medicine
Cook D, Rocker G, Marshall J. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. NEJM. 2003;349:1123-1132.
Drazen JM. Decisions at the end of life. NEJM. 2003;349:1109-1110.
Last reviewed Sep 18, 2003 by ]]>Richard Glickman-Simon, MD]]>
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