Process of life-sustaining treatment in general hospital: withholding and withdrawing

Autor:Lorenzo Socias Crespí - Rosa Poyo-Guerrero Lahoz
Cargo:Intensive Care Unit. Hospital Son Llàtzer. Illes Balears. Spain.
Páginas:67-78
RESUMEN

Background: Limitation of care (LC) is common practice in intensive care units (ICUs) and is associated with high mortality. There is no consensus on its application or the process in itself, sometimes leading futile prolongation of life and greater suffering.Objectives: We aimed to study types of LC, associated mortality and factors that influence endof- life decisions.Material and... (ver resumen completo)

 
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Introduction

Limitation of care (LC) is common practice in intensive care units (ICUs) and is associated with high mortality. However, there is no established consensus on when or how it should be applied and, at times, futile attempts to prolong life may lead to greater suffering for the patients. From the ethical point of view, the decision to withhold life support is no different to the decision to withdraw it, as recognized by a number of authors [1,2,3,4].

Often, personal views of the intensivist influence decisions about LC although this is inappropriate from the ethical standpoint and hinders the application of a uniform standard of care. In studies published on the opinion of health-care professionals, prior quality of life (92%) and future predicted quality of life (83%) are taken into account [5]. It is also true that physicians underestimate the quality of life of patients, whereas patients are more optimistic and are more tolerant of their limitations [6]. In practice, although the recommendations are fully clear, withdrawal of life support is only acceptable for reasons of physiological futility such as, for example, brain death, patients with end-stage multiorgan failure and patients in a vegetative state.

In our study, we aimed to compare withdrawal of life support with withholding of life support and analyze the variables that determine the initiation of the decision process at the end of life.

Material and methods

In this prospective, observational, descriptive study conducted between 1 February 2004 and 28 February 2008, we included 97 patients in whom either withdrawal or withholding of life support was practiced. The study was conducted in the Intensive Care Unit of our hospital, with a catchment population of approximately 250,000 people. It has 350 beds, with all medical and surgical specialties represented except neurosurgery and cardiovascular surgery. The ICU has 14 beds and admits, on average, 700 patients/year, with a mean stay of 5.6 days. During the study period, 1458 patients were admitted to the unit. In 97 patients (6.6%), some form of LC was practiced. These patients were studied prospectively until they died or were discharged from the unit.

The following data were collected for each subject: age, sex, diagnosis on admission, Sequential Organ Failure Assessment (SOFA) at the time of inclusion, Acute Physiology and Chronic Health Evaluation (APACHE) II on admission, life support measures during admission (mechanical ventilation, vasoactive drugs, dialysis, antimicrobial therapy, artificial nutrition), type of LC (withdrawal or withholding of life support), number of failing organs when the decision was made, comorbidity, and the rationale for the decision (futility, prior quality of life or suffering). Withholding or withdrawal of life support was defined as the decision not to apply a medical intervention either by not resorting to it (withholding) or renouncing it when the intervention was not meeting its therapeutic goals (withdrawal). Quality of life was defined as the subjective perception of an individual of living in a dignified state. In our study, in accordance with Rivera Fernández et al [7], we defined four levels of quality of life, based on basic physiologic areas: physical activity, dependence on therapeutic measures, and occupational activity. We defined suffering according to the definition proposed by Casell [8]. Futility was defined as

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a therapeutic measure considered useless because the objective of providing benefit to the patient was very likely to fail. Other data of interest collected were hospital stay, stay in the ICU, time from admission to the ICU until the decision was made and time from making the decision until death or discharge from hospital.

Statistical analysis

Data were presented as absolute numbers and percentages for categoric variables and mean±SD for continuous ones. The ?2test was used for comparing non-continuous variables while the means of continuous variables were compared using the Student t test for unpaired data. A logistic regression model was used to analyze the factors predictive of mortality. Confounding factors of poor prognosis were considered to be age, sex, APACHE II, organ failure at the time of inclusion and comorbidity. Survival and the influence of type of LC were studied using the Kaplan-Meier method.

Results

Between 1 February 2004 and 28 February 2006 we admitted a total of 1458 patients to the ICU. Their mean age was 65.3±15.9 years and 64.6% were women. The mean APACHE II score was 15.4±8.1 and the mean stay was 5.6±9.6 days. In total, 287 patients died (19.7%). The most common diseases on admission were ischemic heart disease (28.1%), severe sepsis (27.4%) and chronic obstructive pulmonary disease (7%). The mortality rate for each of these diseases was 5.9%, 34.8% and 8.9%, respectively. Of the total number of deaths in the ICU, severe sepsis accounted for 48.4%.

Life-prolonging measures were withdrawn or withheld in 97 patients (6.7%). Eighty-five patients...

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