According to an article published in the second October 2008 issue of the American Journal of Respiratory and Critical Care Medicine, doctors in intensive care units (ICUs) often withdraw life support systems over a prolonged period of time as they attempt to balance the difficult needs of their patients and the families of patients. The study, funded by the National Institute of Nursing Research, maintains that physicians make this imperfect compromise more frequently than is commonly believed, but it is linked to a higher satisfaction with care among surviving family members.
Co-author J. Randall Curtis, M.D., M.P.H. (section chief for pulmonary and critical care medicine, Harborview Medical Center and the University of Washington, Seattle) wrote, “We found that sequential withdrawal of life support is not as rare a phenomenon as previously believed…It occurred in nearly half of the patients we studied.”
Data came from medical charts and family questionnaires for over 500 patients who died at the ICU or within 24 hours of discharge from 15 Seattle or Tacoma hospitals. Dr. Curtis and colleagues selected this sample from a pool of 2,003 consecutive patients at these facilities. The patients spent their final days on an average of four life-support systems, from mechanical breathing to feeding by tube.
The researchers found that when the withdrawal processs was longer for patients who had ICU longer stays, families indicated a higher level of satisfaction. “This finding is in the opposite direction to our original hypothesis,” remarks Dr. Curtis, because “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of non-beneficial and sometimes painful therapies in a situation in which life-sustaining therapies are being withdrawn in anticipation of death.”
One potential explanation for this counterintuitive finding lies in poor communication between physicians and families. That is, for families of patients who were removed from life support, a lack of communication slows decision making and delays their 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,” clarifies Dr. Curtis.
Although some families may view sequential withdrawal of life support to be a better route, the situation is nonetheless a consequence of “incomplete decision making [that] serves as a way to compensate for the existing gap between physicians’ decisions and family expectations,” write Dr. Curtis and colleagues.
In addition to their surprising finding, the researchers found that higher family satisfaction was associated with patients who had tubes removed (extubated) before death. This suggests that extubation may be the optimal method for many patients who are withdrawing from life support.
“The take home message” writes 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.”
“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,” conclude the researchers.
Duration of Withdrawal of Life Support in the Intensive Care Unit and Association with Family Satisfaction
Eric Gerstel, Ruth A. Engelberg, Thomas Koepsell, and J. Randall Curtis
American Journal of Respiratory and Critical Care Medicine (2008): Vol 178, pp. 798-804.
10.1164/rccm.200711-1617OC
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Written by: Peter M Crosta