Family Members Should Be Allowed to Remove a Patient From Life Support

BMJ. 2002 Dec seven; 325(7376): 1342–1345.

Withdrawing life support and resolution of conflict with families

What is the best way for the intensive care team to piece of work with a family unit to determine on a program of care when withdrawing or withholding life support?

A high proportion of deaths in intensive care occur later on withdrawal or withholding of life support. In a survey of critical care physicians, 85% of respondents had withheld or withdrawn life back up in the preceding year.^ane A Us report showed a big increment in the proportion of deaths in intensive care that were preceded by a determination to withhold or withdraw life support, from fifty% in 1987-88 to over 90% in 1992-93.ⁱⁱ In many countries, most deaths in intensive care are preceded past a decision to withdraw or withhold life support,^{3 ,4 w1-w4} although the proportion of deaths preceded by withdrawal versus withholding varies.⁴

Although limitation of life back up earlier death is common in nigh intensive intendance units, at that place are wide variations in approaches to cease of life intendance.^{5 ,half dozen w1 w5 w6} In a survey of 131 intensive care units in the United states, the proportion of deaths in which life support was withheld varied from 0% to 67% and the proportion of deaths later on withdrawal of life support varied from 0% to 79%.^five These wide variations suggest the need for increased consensus on all-time practices for managing death in intensive intendance units. In this article, nosotros review the empirical research that can guide physicians in deliberations over whether to withdraw life support, maximising patient and family unit involvement in the decision making process, and negotiating conflicts that may ascend.

Methods

Nosotros performed literature searches with PubMed using the index terms for critical care ("critical intendance" or "intensive intendance" or "mechanical ventilation") and palliative intendance ("palliative intendance" or "end of life"). This gave 493 citations. We besides included the index term "futility" in combination with the critical care terms, yielding 227 citations. Nosotros reviewed all abstracts and selected relevant, research based manufactures.

Summary box

• Many deaths in intensive care occur after withdrawing or withholding life support

• Clinicians and families more often than not make the determination every bit nigh patients are besides ill to participate, merely who takes the atomic number 82 role varies greatly

• Conflict near withholding or withdrawing life support is common between clinicians and families and negotiation of these conflicts requires skillful communication skills

• Good communication by intensive care physicians may shorten the dying process

• Withdrawal of life support is a clinical procedure that requires proficient medical skills, cultural sensitivity, attention to ethical principles, and shut collaboration with patients' families

How are decisions made concerning withholding or withdrawing life back up?

Clinicians and families make nigh of the decisions about life back up in intensive care equally less than v% of patients are able to communicate with clinicians at the fourth dimension.² When facing potential mental incapacitation, ninety% of patients prefer family members to act as the determination makers and asking that decisions be made in conjunction with their physicians.^seven Unfortunately, few patients take ever discussed their resuscitation preferences with a family unit member,^{viii w7} and decisions by surrogates may not accurately reflect patients' preferences.⁹

Physicians also have poor understandings of patients' preferences, and nigh patients do not discuss their preferences with their physicians.^ten Physicians' predictions of their patients' preferences for resuscitation are simply moderately ameliorate than chance.^{xi w8} In addition, some physicians make inaccurate assumptions about resuscitation preferences based on a patient's age or quality of life.^{eleven w9}

Some other complication of the decision making process is that patients desire proxy decision makers to use their judgment rather than be bound by the specifics of accelerate directives. In one written report, 78% of patients stated that if their prior preferences differed from a decision fabricated by their family and doc, they would desire the family and doctor'due south determination followed.¹² These limitations of advance directives and surrogate decision making highlight the importance of clinicians' ability to listen to and understand family concerns and skilfully negotiate treatment decisions.

How can conflicts between clinicians and families be negotiated?

Disharmonize surrounding determination making in intensive intendance units is common. Conflict can arise about issues such as communication styles, interpersonal interactions, and pain control also as well-nigh treatment decisions.^{13 w10} One study of intensive care patients for whom withdrawal of life support was considered institute that conflict occurred between staff and family in 48% of cases, amidst staff in 48%, and amid family unit members in 24%.¹³

The prove on the best way to resolve conflicts suggests that communication, negotiation, and consensus building are the most important tools. Physicians use varying communication and negotiation strategies to resolve conflicts with dying patients.^fourteen The most common approach, listed by 71% of physicians in one report, was directly educating and negotiating with patients about potential misunderstandings. Less common ways of dealing with conflict included deferring to patient requests for benign or uncomplicated treatments (34%), obtaining assist of other family members (16%), and referring to other physicians for provision of disputed care (nine%). Conflict tin can be constructive, uncovering differences in values and legitimate concerns that take been inadequately discussed. Improved communication nigh goals, prognoses, and handling options volition successfully resolve nigh conflicts and may minimise unrealistic requests past patients or families.^{w11 w12}

What is the function of futility in medical conclusion making?

In the example described in box ​ B1, clinicians were frustrated with what they perceived to be the family's requests for "futile" care. In caring for critically ill patients, situations often ascend in which farther life sustaining treatments take a very depression likelihood of success. At this betoken, further intervention may be described as futile, and clinicians may experience strongly that life sustaining therapy should be stopped. In 1991, the American Thoracic Society divers a life sustaining intervention as futile "if reasoning and experience indicate that the intervention would be highly unlikely to effect in a meaningful survival for that patient."¹⁵ Despite cogent descriptions of the potential value of this concept in medical decision making,^16w13 controversy exists virtually what constitutes a futile intervention.¹⁷ Concern has been raised that physicians could corruption this principle by making unilateral judgments about the value of life.^w14

Illustrative case

Ms R, a 52 year sometime woman with severe rheumatoid arthritis and chronic immobility, was brought to the emergency department. Her wellness was poor, although stable, until the morn of admission, when she became disoriented and lethargic. She was admitted to intensive intendance, where she was treated for septic shock secondary to decubitus ulcers and for acute renal failure. On the solar day after admission she was requiring increasing doses of vasopressor drugs and developed astute respiratory distress syndrome. Some members of the intensive care team became increasingly concerned most the "futile" intendance they felt they were providing. The patient'southward family requested that the medical team "do everything" to keep her alive.

Encounter box ​ B2 for follow up.

Most of the literature on medical futility examines the ethical and legal aspects rather than its use in clinical practice. 1 US written report showed that even though physicians believe that futility oftentimes applies in "practice not resuscitate" orders, they do non use the principle unilaterally in the absence of patient or surrogate concurrence.¹⁸ Withal, physicians were often inconsistent in their thinking about futility: in one tertiary of cases, physicians applied the principle in situations where they believed there was a greater than 5% chance of successful event.¹⁸

If the medical futility rationale is part of physicians' determination making processes, it should be conspicuously defined and supported by published data. Whatsoever determination of futility should be discussed with the patient or family members. In virtually cases, patients or families volition hold^{two w15} and may appreciate not having to choose to forego a treatment that is non indicated.^xix However, if patients or families do not concord, the American Medical Association recommends a process be initiated to reconcile differences and that care be continued until reconciliation is achieved.²⁰

How competent are physicians at communicating with family unit members?

Families of critically ill patients consistently charge per unit communication with intensive care clinicians amidst their about of import concerns—more important fifty-fifty than clinical skills.^w16 Studies examining the needs of relatives of intensive care patients indicate that the nigh important needs relate to advice and include having questions answered honestly, understanding the diagnosis and prognosis, and having information explained in understandable terms.²¹ However, physicians are ofttimes poor at discussing cease of life issues, and fifty-fifty when communication occurs, information technology is often ineffective. A study evaluating physician-family unit meetings constitute that 54% of family members had not understood basic features of the diagnosis, prognosis, or treatment.²² Research on discussions of resuscitation status with hospital patients noted that physicians spend 75% of the fourth dimension talking and miss important opportunities to allow patients to discuss their personal values and goals of therapy.²³

Few studies provide empirical evidence to guide clinicians on improving communication. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT) showed that a nurse led communication intervention had no event on the care that dying patients received in intensive care.²⁴ Another study, however, institute that a standardised, multidisciplinary family conference led past an attending medico that focused on goals and outcomes of life support resulted in an earlier transition to palliative care and reduced length of stay in intensive intendance for dying patients.²⁵ This study suggests that improving communication with families can improve the quality of stop of life care. A meliorate understanding of families' needs and concerns may help clinicians to communicate more than effectively.²⁶

What is the all-time mode to withdraw life back up?

The goal of withdrawing life support when expiry is expected is to remove treatments that are no longer desired or indicated and that do not provide comfort to the patient. Whatever handling may be withheld or withdrawn, and most ethicists concur that there is no difference between withholding or withdrawing life supportive treatments.^{15 w17 w18} Many clinicians, however, experience more than comfortable withholding rather than withdrawing treatments.^w19

The withdrawal of life sustaining treatments is a clinical procedure and therefore deserves the aforementioned preparation and expectation of quality as other procedures. Informed consent should exist obtained and should include honest, caring, and culturally sensitive communication with family members, explanations of how interventions will be withdrawn, strategies for assessing and ensuring comfort, information about the patient's expected length of survival, and solicitation of feedback and strong preferences most cease of life intendance.^{27 ,28 w6 w20} Time should be spent discussing, understanding, and accommodating cultural and religious perspectives.²⁹ An explicit programme for withdrawing intendance and handling complications should be formulated: the patient should be in the appropriate setting with irrelevant monitoring removed; the process should be carefully documented, including the reasons for increasing sedation; and outcomes should be evaluated to improve the quality of care.

Evidence suggests that dying patients' physical and emotional suffering is inadequately treated in intensive care units.^{30 w21} In SUPPORT, 40% of patients who died with acute respiratory failure and sepsis had severe pain and dyspnoea during the last three days of life.³¹ A study of cancer patients in intensive care showed a high brunt of pain and other symptoms.³² Some clinicians consciously provide inadequate treatment for pain, even when withdrawing life support, because they fear hastening expiry.^w6 Nevertheless, electric current guidelines recommend placing a loftier priority on adequate symptom control using a combination of morphine or other narcotic with a benzodiazepine, continually infused and titrated until the patient stops showing expressions of discomfort, including grimacing, agitated behaviour, and autonomic hyperactivity.³³ Specific circumstances may likewise justify the utilise of barbiturates, haloperidol, or propofol.^w22

Minimising distress for the patient and family

In one case a decision is made to withdraw life sustaining treatments, the time form of withdrawal should be determined by the potential for discomfort equally treatment is stopped. The only rationale for tapering life sustaining treatment is to allow time to control patients' symptoms. At that place is usually no demand to taper pressor drugs, antibiotics, diet, or most other critical care treatments.

Mechanical ventilation is one of the few life back up treatments that oft cannot exist stopped abruptly. The common arroyo to stopping ventilation (often called rapid last weaning) is gradually to reduce the fractional inspired oxygen concentration to room air and ventilatory support to aught with anticipatory dosing of narcotics as needed for patient comfort. The patient is then placed on a T-piece with humidified air or extubated. Since the term "weaning" suggests the goal is independent spontaneous ventilation, we prefer the phrase "concluding ventilator discontinuation." Limited data exist on whether patients should be extubated. Studies have found no significant difference in patient condolement,^{27 w23} but these studies lack power to discover clinically important differences. Terminal ventilator discontinuation may unnecessarily prolong dying if various steps are prolonged.^w6 The transition from full ventilatory support to T-slice or extubation should take no more than 15-30 minutes.^{28 w24} Families should be warned that death, although expected, is not certain and that the timing can vary.

Neuromuscular blockers serve no therapeutic purpose during withdrawal of life support.^{33 w25-w27} Although paralytic drugs can ease the family unit'southward distress by making the dying patient seem comfy,^w25 they may increase suffering by preventing clinicians from fairly assessing patient discomfort. Paralytic drugs should therefore be stopped before life sustaining therapies are withdrawn and time given for the drug to clear. Nevertheless, 6% of physicians in the Society of Critical Care Medicine written report using neuromuscular blockers at the terminate of life, at to the lowest degree occasionally,^w6 and one study showed 9% of patients received neuromuscular blockers during withdrawal of life support.³⁴

The families' emotional reactions and needs as well need to exist anticipated. Families may believe they are causing the patient'south death by like-minded to withdraw life support. Feelings of guilt should be explored direct and discussed openly. Relatives may experience less encumbered past guilt if physicians strongly recommend that life support be withdrawn rather than asking the family to make the decision. Focusing the family on what the patient would want rather than what the family wants may likewise reduce the family burden. Other family and staff members (nurses, social workers, chaplain) can be enlisted to provide support, and the family should be asked if a priest or other religious adviser should be called before interventions are withdrawn. Many relatives report that the presence of clergy at the time of withdrawing life back up is reassuring.^w10

Boosted educational resources

Curtis JR, Rubenfeld GD, eds. Managing death in the ICU: the transition from cure to condolement. New York: Oxford University Press, 2001

Troug RD, Cist AF, Brackett SE, Burns JP, Curley MA, DeVita MA, et al. Recommendations for the terminate of life intendance in the intensive care unit: the ethics committee of the Society of Disquisitional Care Medicine. Crit Intendance Med 2001;29:2332-48

Promoting Excellence In Cease-Of-Life Care (world wide web.promotingexcellence.org)—an organisation dedicated to improving the wellness intendance of dying people

Primer on disquisitional intendance for patients and their families (world wide web.thoracic.org/assemblies/cc/ccprimer/mainframe2.html)—information from the critical care associates of the American Thoracic Club

Gild of Critical Care Medicine (www.sccm.org)

​

HANK MORGAN/SPL

Nigh deaths in intensive care occur after a decision to withdraw or withhold life support

Case follow upward

The intensive intendance team bundled for a conference with the family. The attention physician asked the family to describe their agreement of the patient's condition. The family was far more than optimistic than her physicians, thinking she had a 50% chance of recovery to her former state of health. The attending doctor then asked the family to tell the team what Ms R was like equally a person. The squad learnt that she had always been full of energy and set and eager to accept on all challenges. They were thus able to appreciate her relatively good quality of life and role in her family.

The team then explained that Ms R's poor underlying health and immune suppression meant that she was unlikely to recover from the progressive septic shock. They explained that high quality medical care is defined both by improvement in health and, when improvement is non possible, by ensuring comfort. The family was unaware that near deaths in intensive intendance occur later withdrawing or withholding life support and, with that data, began to develop more than trust. The team reassured the family that they had time to think everything over and that life support would go along for every bit long equally the family believed it was what Ms R would want. They emphasised that withdrawal of life support did non hateful withdrawal of medical and nursing care and that her pain and other symptoms would continue to exist monitored and treated. The family felt supported by the team and relieved that they had not been pressured into accepting withdrawal of life support.

Ms R remained critically ill with multiple organ dysfunction syndrome and showed no significant improvement despite maximal therapy. After several days, the family unit decided that Ms R would non take wanted ongoing life back up in this situation. The squad explained the procedure of withdrawing life support. They informed the family that she would be unlikely to survive for more than an hr later on withdrawal, although occasionally patients survive longer. The squad besides asked nigh spiritual needs and the family requested a chaplain.

Routine investigations were discontinued and all drugs were stopped except for morphine and lorazepam. Morphine and lorazepam were titrated to comfort during concluding ventilator discontinuation. Ms R'due south family returned to the bedside after her extubation and she died within 30 minutes. A clergyman was with the family when she died.

Supplementary Material

[extra: Additional references]

Footnotes

Funding: This manuscript was supported past an RO1 from the National Institute of Nursing Inquiry (NR-05226-01).

Competing interests: None declared.

Boosted references are available on bmj.com

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124803/