Now, keep up to date
with daily feeds of newly posted stories
about America's Seniors...click on the box
to the left
Withdrawal of Life Support often an
imperfect compromise
Newswise — Intensive Care Unit (ICU) doctors
seeking to balance the complex needs of
their patients and the patients’ families
may make an imperfect compromise,
withdrawing life support systems over a
prolonged period of time.
This practice is much more common than
previously believed, and is also
surprisingly associated with higher
satisfaction with care-at least among
surviving family members.
“We found that sequential withdrawal of life
support is not as rare a phenomenon as
previously believed,” wrote J. Randall
Curtis, M.D., M.P.H., section chief for
pulmonary and critical care medicine at the
Harborview Medical Center and the University
of Washington, in Seattle. “It occurred in
nearly half of the patients we studied.”
The findings will be published in the second
issue for October of the American Journal of
Respiratory and Critical Care Medicine,
published by the American Thoracic Society.
The study was funded by the National
Institute of Nursing Research.
Dr. Curtis and colleagues examined medical
charts and family questionnaires for more
than 500 patients who had died at the ICU or
within 24 hours of discharge out of a pool
of 2,003 consecutive patients in 15 Seattle
or Tacoma hospitals.
During their final days, the patients
studied were on a median of four
life-support systems, from mechanical
ventilation to tube feeding.
Interestingly, among patients whose stays at
the ICU were more prolonged, families seemed
to be more satisfied when the withdrawal
process was longer.
“This finding is in the opposite direction
to our original hypothesis,” wrote Dr.
Curtis, noting that “a longer duration of
withdrawal of life support seems unlikely to
be beneficial for the patient because it
represents the prolongation of
non-beneficial and sometimes painful
therapies in a situation in which
life-sustaining therapies are being
withdrawn in anticipation of death.”
A possible explanation for the higher rate
of satisfaction among the families of
patients who were removed from life support
over time is that poor communication between
physicians and families impedes decision
making and delays the families’ emotional
readiness.
“Families need time and support to move from
a situation of focusing on hoping for the
patient's survival, to a situation in which
they have accepted that death is inevitable
and they are preparing for the best death
possible.
"If
families are not adequately prepared for
such a transition, withholding all therapies
the same day, followed by a quick death,
could be experienced as abandonment,” said
Dr. Curtis.
Dr. Curtis and colleagues believe that,
while sequential withdrawal of life support
may be experienced more positively by some
families, it is nonetheless a result of
“incomplete decision making [that] serves as
a way to compensate for the existing gap
between physicians' decisions and family
expectations.”
The study also found if patients were
extubated prior to death, family
satisfaction tended to be higher, suggesting
that extubation may be the best approach for
many patients undergoing withdrawal of life
support.
“The take home message” says Dr. Curtis “is
not to prolong the withdrawal of
life-sustaining therapies to the possible
detriment of the patient, but to facilitate
better communication between ICU clinicians
and patients’ families.
"When physicians make
a decision to withdraw support, they have
often not prepared the family sufficiently
and physicians may consequently embark on
‘stuttering’ withdrawal of life support in
order to have more time to prepare the
family.”
Dr. Curtis concluded: “A better solution for
improving family experience while also
providing the best possible care to patients
is to prepare the family for the possibility
of the patient’s death earlier in the ICU
stay rather than waiting until the
physicians have decided that withdrawal of
life support is indicated.”
...
...
...