Withholding and Withdrawal of Therapy in New Zealand Intensive Care Units (ICUs): A Survey of Clinical Directors

Withdrawing and withholding life-support therapy in patients who are unlikely to survive despite treatment are common practices in intensive care units (ICUs). The literature suggests there is a large variation in practice between different ICUs in different parts of the world. We conducted a postal survey among all public ICUs in New Zealand to investigate the pattern of practice in withholding and withdrawal of therapy. Nineteen ICUs responded to this survey and they represented 74% of all the public ICU beds and 83% of the annual ICU admissions. The percentage of ICU admissions with therapy withdrawn or withheld was less than 10% in most ICUs. Only a small percentage (21%) of ICUs had a formal policy in withholding and withdrawal of therapy. The timing of making the decision to withhold or withdraw therapy was very variable. The patient and/or the family, the primary medical team consultant, two or more ICU consultants, and ICU nurses were usually involved in the decision making process. ICU nurses were more commonly involved in the decision making process in smaller ICUs (5 beds vs 10 beds, P=0.03). The patient's pre-ICU quality of life, medical comorbidities, predicted mortality, predicted post-ICU quality of life, and the family's wishes were important factors in deciding whether ICU therapy would be withheld or withdrawn. Hospice ward or the patient's home was the preferred place for palliative care in 32% of the responses.

[Limitation of Vital Support in a Chilean Pediatric Intensive Care Unit: 2004-2014]

OBJECTIVE

Describe the frequency and characteristics of PICU patients who undergo a process of withholding or withdrawing life-sustaining treatment (LTSV), between 2004 y 2014.

PATIENTS AND METHOD

A retrospective, observational descriptive study, using two documents for quality assessment in the PICU of Hospital Roberto del Río: 1) daily individual patient tracking log and 2) daily record of quality indicators, including LTSV, both updated daily at the morning visit. All PICU patients with an ethical dilemma during their PICU stay in which a LTSV was proposed were included. We men tion patients rejected for admission in the ICU and those who died in basic units of the hospital with LTSV.

RESULTS

In 118 patients of 7821 PICU admissions (1,5%) we determined a LTSV: ONR (Non Resuscitation Order) for all of them, ONI (Non Innovation Order) in 78,8%, withdrawal of some therapeutics in 14,4% and withdrawal of active mechanical ventilation in 6,8%. The basic diagnosis was 23,7% for each neurologic and oncologic diseases. The predominant pathophysiologic condition leading to a LTSV was severe chronic neurologic damage (39%). The length of stay was threefold the mean PICU stay, with a large variability due to expectable individual factors when ethic decisions are involved.

CONCLUSION

LTSV is feasible when the team is involved and this perspective is part of daily clinical analysis. The wide individual variability in the LTSV process is expectable in ethical decisions.

End-of-life decisions for children under 1 year of age in the Netherlands: decreased frequency of administration of drugs to deliberately hasten death

OBJECTIVE

To assess whether the frequency of end-of-life decisions for children under 1 year of age in the Netherlands has changed since ultrasound examination around 20 weeks of gestation became routine in 2007 and after a legal provision for deliberately ending the life of a newborn was set up that same year.

METHODOLOGY

This was a recurrent nationwide cross-sectional study in the Netherlands. In 2010, a sample of death certificates from children under 1 year of age was derived from the central death registry. All 223 deaths that occurred in a 4-month study period were included. Physicians who had reported a non-sudden death (n=206) were sent a questionnaire on the end-of-life decisions made. 160 questionnaires were returned (response 78%).

FINDINGS

In 2010, 63% of all deaths of children under 1 year of age were preceded by an end-of-life decision-a percentage comparable to other times when this study was conducted (1995, 2001, 2005). These end-of-life decisions were mainly decisions to withdraw or withhold potentially life-sustaining treatment. In 2010, the percentage of cases in which drugs were administered with the explicit intention to hasten death was 1%, while in 1995 and 2001, this was 9% and in 2005, this was 8%.

DISCUSSION AND CONCLUSION

There has been a reduction of infant deaths that followed administration of drugs with the explicit intention to hasten death. One explanation for this reduction relates to the introduction of routine ultrasound examination around 20 weeks of gestation. In addition, the introduction of legal criteria and a review process for deliberately ending the life of a newborn may have left Dutch physicians with less room to hasten death.

End-of-life decisions in dutch neonatology

This contribution describes the regulation of end-of-life decisions in neonatology in the Netherlands. An account is given of the process of formulating rules, which includes a report by the Dutch Association for Paediatrics, two Court rulings, a report by a Consultation Group appointed by the Ministry of Health and a professional Protocol regulating deliberate ending of life in neonatology that was subsequently adopted as the regulation of this type of decision-making at the national level. The paper presents Dutch and comparative data on the attitude of the medical profession towards end-of-life decisions in neonatology and the frequency of such decisions in medical practice.

A pilot audit of the process of end-of-life decision-making in the intensive care unit

BACKGROUND

Withdrawal of potentially life-prolonging treatments is a common procedure in most intensive care units. Until recently, quality improvement activities have been hampered by the absence of a clear sense of "best practice" in this complex area.

OBJECTIVE

This pilot audit addresses the feasibility of developing an end-of-life (EOL) decision-making audit and quality improvement tool and applying it in the intensive care setting.

METHODS

Between November 2005 and April 2006, treatment was withdrawn from 47 patients in our ICU. Their charts were audited, and a structured interview was conducted with the intensivist who documented the decision. We defined treatment withdrawal as the cessation of mechanical ventilation and all other forms of life support in the anticipation of the patient's death.

RESULTS

55% of ICU deaths were the result of treatment withdrawal. Overwhelmingly, treatment failure or futility was the reason cited for withdrawal. There were no cases of conflict between the medical team and the patient's family. The level of confidence among intensivists about EOL decision-making was high. Consultation with ICU colleagues was rated as the most helpful factor in decisionmaking. Intensivists wished for earlier and more active support from the admitting medical officers in decisionmaking. Strong support for advance planning and for audit of EOL decision-making was highlighted.

CONCLUSIONS

A current ICU quality improvement review lists EOL management as a possible audit item (Curtis et al. Crit Care Med 2006; 34: 211). Our study demonstrated the feasibility of developing a quality improvement tool for EOL decision-making and applying it in the intensive care setting. As evidence about the process of EOL decisionmaking accumulates, that process should become a component of quality assurance audit in intensive care.

The empirical slippery slope from voluntary to non-voluntary euthanasia

This article examines the evidence for the empirical argument that there is a slippery slope between the legalization of voluntary and non-voluntary euthanasia. The main source of evidence in relation to this argument comes from the Netherlands. The argument is only effective against legalization if it is legalization which causes the slippery slope. Moreover, it is only effective if it is used comparatively-to show that the slope is more slippery in jurisdictions which have legalized voluntary euthanasia than it is in jurisdictions which have not done so. Both of these elements are examined comparatively.

Intentionally hastening death by withholding or withdrawing treatment

PURPOSE

This study aims to provide empirical data on physicians' intentions in withholding and withdrawing treatment, and to discuss possible implications for the ethical debate.

BASIC PROCEDURES

The data presented come from EURELD, a large research project designed to investigate medical end-of-life decisions in six European countries. A continuous random sample of death certificates formed the basis for contacting doctors who had attended the deceased; the doctors were asked to complete, strictly anonymously, mail questionnaires on the decisions taken at the end of their patients' lives.

MAIN FINDINGS

In the six countries studied, physicians reported they had the explicit intention of hastening the end of life in 45% of all treatments that were withheld/ withdrawn. The highest numbers of cases with an underlying intention of hastening the end of life were found in Switzerland and Sweden (52% and 51%, respectively); the lowest figures came from Denmark and Belgium (36% and 38%). Middle-ranking countries were Italy (42%) and the Netherlands (45%). Overall, dialysis and respiration were comparatively more often forgone with the explicit intent to hasten the end of life (57% and 54%, respectively), whereas a particularly low percentage of cases with such an explicit intention was found for oncotherapy (34%).

PRINCIPAL CONCLUSIONS

In almost every second case, a medical decision to withhold or withdraw treatment is taken with the explicit intention of hastening the end of the patient's life. No clear association can be found between the intent to hasten the end of life and features of the treatment forgone that can be determined objectively, such as the likelihood and extent of a life-shortening effect, the immediacy of death, or the expected burden of any potential life-sustaining measure. The findings of the study challenge the usefulness of doctors' intentions with regard to hastening the end of life as criteria for moral judgements on decisions to withhold or withdraw medical treatment.

[Insight into end-of-life decisions in newborns in Flanders, Belgium]

In the Netherlands, as in many other European countries, the majority of deaths in newborns are preceded by end-of-life decisions. In most cases, these decisions concern the withholding or withdrawing of treatment. Drugs with a potential life-shortening effect are often prescribed in the terminal phase of treatment of newborns to alleviate their suffering. The use of lethal drugs in order to deliberately end the life of newborns with a very poor prognosis and intractable severe suffering has been reported by Dutch paediatricians. Recently published data about end-of-life decisions in newborns in Flanders have shown that paediatricians in Flanders also consider the deliberate ending of life in newborns and young infants to be an acceptable option in exceptional circumstances. Real insight into the existing practice remains limited because the deliberate ending of life legally qualifies as murder in both countries. Few cases are reported because of the physician's fear of prosecution. Physicians in Flanders and in the Netherlands have pleaded for a different system of control of the deliberate ending of life in newborns. The Dutch government has recently announced the instalment of a multidisciplinary committee of experts to whom all cases must be reported. The advice of the committee to the prosecuting authorities will be crucial. It is expected that this change will increase the willingness to report cases.

Variation in end-of-life decision making between critical care consultants

Considerable variation in end-of-life decision making is reported between intensive care units in the United Kingdom, possibly because of differences in casemix. Senior medical staff within any one unit should, however, be consistent in such decision making. We reviewed the medical records for a 4-year period to establish if there was consistency in our own unit. This revealed considerable variation in the apparent willingness of consultants to make end-of-life decisions, emphasising the subjective nature of these decisions. Personality typing (Myers-Briggs Type Indicator) of consultants revealed that those who had made more than the expected number of decisions had scores towards the judging end of the judging/perceiving domain.

[No conspicuous changes in the practice of medical end-of-life decision-making for neonates and infants in the Netherlands in 2001 as compared to 1995]

OBJECTIVE

To establish whether the practice of end-of-life decision-making for neonates and infants under the age of 1 in the Netherlands in 2000 was different from that in 1995.

DESIGN

Retrospective descriptive and comparative study.

METHODS

In both years, all deaths of children under the age of one year that took place in August-November (1995: n = 338; 2001: n = 347) were studied. The response rate was 96% in 1995 and 84% in 2001. The questionnaires which were sent to the physicians who reported the deaths, included structured questions about whether or not death had been preceded by end-of-life decisions, i.e. decisions to withhold or withdraw potentially life-prolonging treatment or to administer (potentially) life-shortening drugs, and questions about the decision-making process.

RESULTS

The proportion of end-of-life decisions increased slightly from 62% to 68% of all deaths in the first year of life, but the difference was not statistically significant. The large majority of these decisions involved withholding or withdrawing life-sustaining treatment. The frequency of decisions to actively terminate the life of an infant who was not dependent on life-sustaining treatment remained stable at 1%. The proportion of decisions that had been discussed with the parents increased slightly, from 91% in 1995 to 97% in 2001; similar percentages of the decisions had been discussed with other physicians. The percentage of decisions that had been discussed with the nursing staff decreased from 40 in 1995 to 28 in 2001.

CONCLUSION

The findings suggest that the practice of end-of-life decision-making in neonatology was rather stable between 1995 and 2001. The frequency of the active termination of life had not increased, despite the new euthanasia regulation in the Netherlands.

Medical End-of-Life Decisions for Children in the Netherlands

BACKGROUND

Most end-of-life decision-making studies have, until now, involved either the general population or newborn infants.

OBJECTIVE

To assess the frequency of end-of-life decisions preceding child death and the characteristics of the decision-making process in the Netherlands.

METHODS

Two studies were performed. The first was a death certificate study in which all 129 physicians reporting the death of a child aged between 1 and 17 years in the period August to December 2001 received a written questionnaire; the second was an interview study in which face-to-face interviews were held with 63 physicians working in pediatric hospital departments.

RESULTS

Some 36% of all deaths of children between the ages of 1 and 17 years during the relevant period were preceded by an end-of-life decision: 12% by a decision to refrain from potentially life-prolonging treatment; 21% by the alleviation of pain or symptoms with a possible life-shortening effect; and 2.7% by the use of drugs with the explicit intention of hastening death. The latter decision was made at the child's request in 0.7% and at the request of the family in 2% of cases. The interview study examined 76 cases of end-of-life decision making. End-of-life decisions were discussed with all 9 competent and 3 partly competent children, with the parents in all cases, with other physicians in 75 cases, and with nurses in 66 cases.

CONCLUSIONS

While not inconsiderable, the percentage of end-of-life decisions was lower for children than for adults and newborn infants. Most children are not considered to be able to participate in the decision-making process. Decisions are generally discussed with parents and other caregivers and, if possible, with the child.

Evaluation of Changes in Forgoing Life-Sustaining Treatment in Israeli ICU Patients

INTRODUCTION

Over the last several years, there have been legal decisions and changes in medical directives concerning end-of-life decisions in Israel.

METHODS

The data were compared to evaluate the changes in the frequency and types of forgoing of life-sustaining treatment (FLST) in patients who were admitted to the ICU during period I (November 1994 to July 1995) and period II (January 1998 to January 1999).

RESULTS

During period I, there were 385 ICU admissions, and during period II there were 627 ICU admissions. In period I, FLST or death occurred in 13.5% of patients, and in 12% in period II. There was no significant difference in cardiopulmonary resuscitation (9% vs 13%, respectively), withholding therapy (90% vs 91%, respectively), or withdrawing therapy (0% vs 0%, respectively) between the two study periods.

CONCLUSIONS

There was no significant change in the frequency or types of FLST in an Israeli ICU between 1994 and 1998, despite passage of a new Patients' Rights Law and the issuing of a Ministry of Health directive on the treatment of the terminally ill, both of which occurred in 1996, and recent district court decisions favoring the termination of life-sustaining therapies.

Factors associated with nurse assessment of the quality of dying and death in the intensive care unit*

OBJECTIVE

To determine the feasibility of using nurse ratings of quality of dying and death to assess quality of end-of-life care in the intensive care unit and to determine factors associated with nurse assessment of the quality of dying and death for patients dying in the intensive care unit.

DESIGN

Prospective cohort study.

SETTING

Hospital intensive care unit.

PATIENTS

178 patients who died in an intensive care unit during a 10-month period at one hospital.

INTERVENTIONS

Nurses completed a 14-item questionnaire measuring the quality of dying and death in the intensive care unit (QODD); standardized chart reviews were also completed.

MEASUREMENTS AND MAIN RESULTS

Five variables were found to be associated with QODD scores. Higher (better) scores were significantly associated with having someone present at the time of death (p <.001), having life support withdrawn (p =.006), having an acute diagnosis such as intracranial hemorrhage or trauma (p =.007), not having cardiopulmonary resuscitation in the last 8 hrs of life (p <.001), and being cared for by the neurosurgery or neurology services (p =.002). Patient age, chronic disease, and Glasgow Coma Scale scores were not associated with the 14-item QODD. Using multivariate analyses, we identified three variables as independent predictors of the QODD score: a) not having cardiopulmonary resuscitation performed in the last 8 hrs of life; b) having someone present at the moment of death; and c) being cared for by neurosurgery or neurology services.

CONCLUSIONS

Intensive care unit nurse assessment of quality of dying and death is a feasible method for obtaining quality ratings. Based on nurse assessments, this study provides evidence of some potential targets for interventions to improve the quality of dying for some patients: having someone present at the moment of death and not having cardiopulmonary resuscitation in the last 8 hrs of life. If nurse-assessed quality of dying is to be a useful tool for measuring and improving quality of end-of-life care, it is important to understand the factors associated with nurse ratings.

The incidence and characteristics of end-of-life decisions by GPs in Belgium

BACKGROUND

Medical end-of-life decisions (ELDs) have been discussed for several years in different countries, but little is known about the involvement of GPs in these ELDs.

OBJECTIVES

The aim of the present study was to establish the incidence and characteristics of ELDs by GPs.

METHOD

We selected 3999 deaths, a 20% random sample of all registered deaths during the first 4 months of 1998 in Flanders, Belgium, and mailed anonymous questionnaires to the attesting physicians. Here we focus exclusively on the 1647 deaths certified by GPs.

RESULTS

The GPs returned 1067 questionnaires (response rate of 64.8%). At least one ELD was made in 39.5% [95% confidence interval (CI) 37.8-41.2] of all primary care deaths. The incidence of euthanasia (including physician-assisted suicide) was 1.5% (95% CI 0.9-2.3) (incidence higher among more educated patients and at home), of administration of lethal drugs without the patient's explicit request 3.8% (95% CI 2.9-5.0) (higher among cancer patients), of alleviation of pain and symptoms with possibly life-shortening effect 18.6% (95% CI 17.0-20.2) (higher among cancer patients and married patients) and of non-treatment decisions 15.6% (95% CI 14.2-17.2) (higher among cancer patients and in nursing homes). The decision was not discussed with the patient in three out of four of the ELDs. A colleague was consulted in one in four ELD cases.

CONCLUSION

ELDs are common in general practice in Flanders, Belgium, despite the restrictive law concerning euthanasia at the time of this study. The incidence of these ELDs varies with cause and place of death, the patient's education and the GP's religion and age. Requirements of prudent practice regarding ELDs are rather poorly met by GPs. Further international research and debate is needed to highlight the GPs' important role in end-of-life care.

Practices of anaesthesiologists with regard to withholding and withdrawal of life support from the critically ill in Turkey

BACKGROUND

To determine practices of Turkish anaesthesiologists with regard to withholding and withdrawal of life support from the critically ill.

METHODS

An anonymous questionnaire consisting of 18 questions was mailed to 439 members of the Turkish Society of Anaesthesiology and Reanimation.

RESULTS

Three hundred and 69 questionnaires were returned (84% response). Over 90% of the respondents indicated that they were Muslim. We found that 66% of respondents had initiated written or oral do-not-resuscitate orders, most frequently after discussion with colleagues (82%).

CONCLUSIONS

While a number of similarities were found between Turkish anaesthesiologists and those from other countries, some specific differences could be identified, particularly related to consensus decision-making and sharing information with other providers and the value of Ethics Committees in the decision-making process.

Non-voluntary and involuntary euthanasia in The Netherlands: Dutch perspectives

During the summer of 1999, twenty-eight interviews with some of the leading authorities on euthanasia policy were conducted in the Netherlands. They were asked about cases of non-voluntary (when patients are incompetent) and involuntary euthanasia (when patients are competent and made no request to die). This study reports the main findings, showing that most respondents are quite complacent with regard to breaches of the guideline that require the patient's consent as a prerequisite to performance of euthanasia.

Attitudes towards euthanasia among physicians, nurses and the general public in Finland

The object of this study was to investigate the attitudes of physicians, nurses and the general public to physician-assisted suicide (PAS), active voluntary euthanasia (AVE) and passive euthanasia (PE) in Finland. Respondents received a postal questionnaire to evaluate the acceptability of euthanasia in five scenarios, which were imaginary patient cases. Age, severity of pain and prognosis of the disease were presented as background factors in these scenarios. This work was carried out in Finland in 1998. The respondents include a random selection of 814 physicians (506 responded, 62%), 800 nurses (582 responded, 68%) and 1000 representatives of the general public (587 responded, 59%).Thirty-four percent of the physicians, 46% of the nurses and 50% of the general public agreed that euthanasia would be acceptable in some situations. Of the scenarios, PE was most often considered acceptable in cases of severe dementia (physicians 88%, nurses 79% and general public 64%). In the same scenario, 8% of physicians, 23% of nurses and 48% of general public accepted AVE. In the scenario of an incurable cancer, 20% of the physicians, 34% of the nurses and 42% of the general public accepted PAS. All forms of euthanasia were generally more acceptable in older, than in younger, scenario patients. This paper conclude that PE was largely accepted among Finnish medical professionals and the general public. Only a minority favored AVE and PAS.

Withdrawing and withholding life support in the intensive care unit: a Spanish prospective multi-centre observational study

OBJECTIVE

To determine how frequently life support is withheld or withdrawn from adult critically ill patients, and how physicians and patients families agree on the decision regarding the limitation of life support.

DESIGN

Prospective multi-centre cohort study.

SETTING

Six adult medical-surgical Spanish intensive care units (ICUs).

PATIENTS AND PARTICIPANTS

Three thousand four hundred ninety-eight consecutive patients admitted to six ICUs were enrolled.

MEASUREMENTS AND RESULTS

Data collected included age, sex, SAPS II score on admission and within 24 h of the decision to limit treatment, length of ICU stay, outcome at ICU discharge, cause and mode of death, time to death after the decision to withhold or withdraw life support, consultation and agreement with patient's family regarding withholding or withdrawal, and the modalities of therapies withdrawn or withheld. Two hundred twenty-six (6.6%) of 3,498 patients had therapy withheld or withdrawn and 221 of them died in the ICU. Age, SAPS II and length of ICU stay were significantly higher in patients dying patients who had therapy withheld or withdrawn than in patients dying despite active treatment. The proposal to withhold or withdraw life support was initiated by physicians in 210 (92.9%) of 226 patients and by the family in the remaining cases. The patient's family was not involved in the decision to withhold or withdraw life support therapy in 64 (28.3%) of 226 cases. Only 21 (9%) patients had expressed their wish to decline life-prolonging therapy prior to ICU admission.

CONCLUSIONS

The withholding and withdrawing of treatment was frequent in critically ill patients and was initiated primarily by physicians.

A population-based study of geriatric trauma in a rural state

BACKGROUND

Urban geriatric trauma patients are known to die more often than their younger counterparts. Little is known of the fate of geriatric trauma patients in a rural environment where delays to definitive treatment are frequent. We hypothesized that rural trauma patients would do worse than their urban counterparts because of prolonged delays to definitive care.

METHODS

Five-year retrospective analysis of all trauma deaths occurring within a rural state and retrospective outcome analysis of trauma patients admitted to a tertiary care facility who were less than 55 years old (defined as young) and 55 or more years old (defined as old). Outcome analysis was performed comparing old and young rural hospitalized patients to the Major Trauma Outcome Study data set collected in major urban trauma centers.

RESULTS

Of the total trauma deaths in the state, 32.5% were old. Old patients were less likely to die at the scene of the injury than were their younger counterparts (R2 = 0.84, p < 0.001). Hospitalized old patients had a significantly higher mean Revised Trauma Score and a significantly lower Injury Severity Score, a higher complication rate, and a higher mortality rate than did hospitalized young patients. The young group had a significantly better survival (W = 0.59, Z = -3.49, p = 0.0001) than the MTOS data set, but the old group had a significantly worse survival (W = -1.8, Z = -3.49, p = 0.001).

CONCLUSION

In a rural environment, old trauma patients die more commonly in the hospital than their younger counterparts, who die more commonly at the scene. Old trauma patients who die in the hospital were less severely injured than their younger counterparts who died in the hospital. Old patients admitted to this rural trauma center have a significantly worse survival than their urban counterparts despite the fact that young rural trauma patients do significantly better than their urban counterparts. Understanding the demographics of rural geriatric trauma may be useful in allocating resources in rural trauma system design. It must be understood that despite relatively low injury severity and physiologic stability, there is a significant potential for rural geriatric trauma patients to do poorly.

Identifying futility in a paediatric critical care setting: a prospective observational study

AIMS

To determine the extent of futile care provided to critically ill children admitted to a paediatric intensive care setting.

METHODS

Prospective evaluation of consecutive admissions to a 20 bedded multidisciplinary paediatric intensive care unit of a North London teaching hospital over a nine month period. Three previously defined criteria for futility were used: (1) imminent demise futility (those with a mortality risk greater than 90% using the Paediatric Risk of Mortality (PRISM II) score); (2) lethal condition futility (those with conditions incompatible with long term survival); and (3) qualitative futility (those with unacceptable quality of life and high morbidity).

RESULTS

A total of 662 children accounting for 3409 patient bed days were studied. Thirty four patients fulfilled at least one of the criteria for futility, and used a total of 104 bed days (3%). Only 33 (0.9%) bed days were used by patients with mortality risk greater than 90%, 60 (1.8%) by patients with poor long term prognosis, and 16 (0.5%) by those with poor quality of life. Nineteen of 34 patients died; withdrawal of treatment was the mode of death in 15 (79%).

CONCLUSIONS

Cost containment initiatives focusing on futility in the paediatric intensive care unit setting are unlikely to be successful as only relatively small amounts of resources were used in providing futile care. Paediatricians are recognising futility early and may have taken ethically appropriate measures to limit care that is futile.

Withholding and withdrawal of life support in intensive-care units in France: a prospective survey. French LATAREA Group

BACKGROUND

In France, there are no guidelines available on withholding and withdrawal of life-sustaining treatments, and information on the frequency of such decisions is scarce.

METHODS

We undertook a prospective 2-month survey in 113, of a total of 220, intensive-care units (ICUs) in France to study the frequency of, and processes leading to, decisions to withhold and withdraw life-sustaining treatments.

FINDINGS

Life-supporting therapies were withheld or withdrawn in 807 (11.0%) of 7309 patients (withholding in 336 [4.6%] and withdrawal in 471 [6.4%], preceded in 358 by withholding). Of 1175 deaths in ICU, 628 (53%) were preceded by a decision to limit life-supporting therapies. Futility and poor expected quality of life were the most frequently cited reasons. Decisions were strongly correlated with the simplified acute physiological score, but an independent centre effect persisted after adjustment for this score. Decisions were mostly taken by all the ICU medical staff, with (54%) or without (34%) the nursing staff; however, a single physician made decisions in 12% of cases. The patient's family was involved in the decision-making process in 44% of cases. The patient's willingness to limit his or her own care was known in only 8% of the cases; only 0.5% of the patients were involved in decisions.

INTERPRETATION

Withholding and withdrawal of life-support therapies are widely practised in French ICUs, despite their prohibition by the French legislation. The lack of an official statement from French scientific bodies may explain several limitations on the various steps of the decision-making process.

End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey

BACKGROUND

Our study is a repeat of the Dutch death-certificate study on end-of-life decisions (ELDs). The main objective was to estimate the frequency of euthanasia (the administration of lethal drugs with the explicit intention of shortening the patient's life at the patient's explicit request), physician-assisted suicide (PAS), and other ELDs in medical practice in Flanders, Belgium.

METHODS

A 20% random sample of 3999 deaths was selected from all deaths recorded between Jan 1 and April 30, 1998. The physicians who signed the corresponding death certificates received one questionnaire by post per death.

FINDINGS

The physicians' response rate was 1355 (52%). 1925 deaths were described. The results were corrected for non-response bias, and extrapolated to estimated annual rates after seasonal adjustment for death causes, and we estimate that 705 (1.3%, 95% CI 1.0-1.6) deaths resulted from euthanasia or PAS. In 1796 (3.2%, 2.7-3.8) cases, lethal drugs were given without the explicit request of the patient. Alleviation of pain and symptoms with opioids in doses with a potential life-shortening effect preceded death in 10,416 (18.5%, 17.3-19.7) cases and non-treatment decisions in 9218 (16.4%, 15.3-17.5) cases, of which 3261 (5.8%, 5.1-6.5) with the explicit intention of ending the patient's life.

INTERPRETATION

ELDs are prominent in medical practice in Flanders. The frequency of deaths preceded by an ELD is similar to that in the Netherlands, but lower than that in Australia. However, in Flanders the rate of administration of lethal drugs to patients without their explicit request is similar to Australia, and significantly higher than that in the Netherlands.

Patient race and decisions to withhold or withdraw life-sustaining treatments for seriously ill hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

PURPOSE

Patient race is associated with decreased resource use for seriously ill hospitalized adults. We studied whether this difference in resource use can be attributed to more frequent or earlier decisions to withhold or withdraw life-sustaining therapies.

SUBJECTS AND METHODS

We studied adults with one of nine illnesses that are associated with an average 6-month mortality of 50% who were hospitalized at five geographically diverse teaching hospitals participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). We examined the presence and timing of decisions to withhold or withdraw ventilator support and dialysis, and decisions to withhold surgery. Analyses were adjusted for demographic characteristics, prognosis, severity of illness, function, and patients' preferences for life-extending care.

RESULTS

The mean (+/- SD) age of the patients was 63 +/- 16 years; 16% were African-American, 44% were women, and 53% survived for 6 months or longer. Of the 9,076 patients, 5,349 (59%) had chart documentation that ventilator support had been considered in the event the patient's condition required such a treatment to sustain life, 2,975 charts (33%) had documentation regarding major surgery, and 1,293 (14%) had documentation of discussions about dialysis. There were no significant differences in the unadjusted rates of decisions to withhold or withdraw treatment among African-Americans compared with non-African-Americans: among African-Americans, 33% had a decision made to withhold or withdraw ventilator support compared with 35% among other patients, 14% had a decision made to withhold major surgery compared with 12% among other patients, and 25% had a decision made to withhold or withdraw dialysis compared with 30% among other patients (P >0.05 for all comparisons). After adjustment for demographic characteristics, prognosis, illness severity, function, and preferences for care, there were no differences in the timing or rate of decisions to withhold or withdraw treatments among African-Americans compared with non-African-American patients.

CONCLUSION

Patient race does not appear to be associated with decisions to withhold or withdraw ventilator support or dialysis, or to withhold major surgery, in seriously ill hospitalized adults.

Forgoing life support in western European intensive care units: the results of an ethical questionnaire

OBJECTIVE

To determine current views of European intensive care physicians regarding end-of-life decisions.

DESIGN

A questionnaire was sent to all physician members of the European Society of Intensive Care Medicine. All questionnaires were anonymous.

RESULTS

A total of 504 completed questionnaires from 16 western European countries were analyzed. Eighty-seven percent of the respondents were male. Forty-six percent of respondents said that intensive care unit admissions were generally or commonly affected by bed shortages, particularly in the south. Nevertheless, 73% of units frequently admit patients with no hope of survival, although only 33% of respondents felt that such patients should be admitted. Eighty percent of respondents felt that written do-not-resuscitate orders should be applied, but only 58% did so, with a wide variation according to country (from 8% in Italy to 91% in The Netherlands). Ninety-three percent of physicians sometimes withhold treatment from patients with no hope of a meaningful life, but withdrawal of treatment is less common. Forty percent of respondents said that they would deliberately administer large doses of drugs to such patients until death ensued. Forty-nine percent of respondents involved staff, patients, and family in end-of-life decisions. Forty-five percent of respondents felt that an ethics consultation was useful in such situations. Physicians in the countries of southern Europe were less likely than those in the north to apply do-not-resuscitate orders, withhold treatment, and discuss such issues with the patients. However, they were more likely to value the opinion of an ethics consultant.

CONCLUSIONS

Intensive care unit admissions are frequently limited by the availability of beds across Europe, particularly in the south and in the United Kingdom, yet 73% of intensivists still admit patients with no hope of survival. When treating patients with no hope of survival, 40% of intensivists will deliberately administer large doses of drugs until death ensues. There are interesting differences between what a physician actually does and what he or she believes should be done with regard to various ethical questions. Important differences in attitudes also exist between European countries.

A national survey of end-of-life care for critically ill patients

In some intensive care units (ICUs), fewer patients who die now undergo attempts at cardiopulmonary resuscitation (CPR), and many more have life support actively withdrawn prior to death than did a decade ago. To determine the frequency of withdrawal of life support, we contacted every American postgraduate training program with significant clinical exposure to critical care medicine, asking them prospectively to classify patients who died into one of five mutually exclusive categories. We received data from 131 ICUs at 110 institutions in 38 states. There were 6,303 deaths, of which 393 patients were brain dead. Of the remaining 5,910 patients who died, 1,544 (23%) received full ICU care including failed cardiopulmonary resuscitation (CPR); 1,430 (22%) received full ICU care without CPR; 797 (10%) had life support withheld; and 2,139 (38%) had life support withdrawn. There was wide variation in practice among ICUs, with ranges of 4 to 79%, 0 to 83%, 0 to 67%, and 0 to 79% in these four categories, respectively. Variation was not related to ICU type, hospital type, number of admissions, or ICU mortality. We conclude that limitation of life support prior to death is the predominant practice in American ICUs associated with critical care training programs. There is wide variation in end-of-life care, and efforts are needed to understand practice patterns and to establish standards of care for patients dying in ICUs.

An audit of treatment withdrawal in one hundred patients on a general ICU

The audit found that 72.6% of patients who died had treatment withdrawn. Three organ failures were most often present in patients when treatment was withdrawn. Withdrawal of treatment did not mean the cessation of care. Variation in involvement was demonstrated with different consultants.

Withholding and withdrawing dialysis: the role of physician specialty and education and patient functional status

Withholding and withdrawing dialysis are subjects of major concern to nephrologists, because both result in a significant number of end-stage renal disease (ESRD) patient deaths. The medical literature on withholding dialysis is extremely limited, and that on withdrawing dialysis consists mainly of retrospective studies from the 1980s. The present study was conducted to identify ways to improve dialysis decision making by providing a current understanding of how decisions to withhold or withdraw dialysis are being made and by examining whether some patients who might benefit from dialysis are not being referred. In 1995, 22 of 27 (82%) nephrologists practicing in West Virginia agreed to participate in a year-long prospective study in which they completed forms on each patient from whom they withheld or withdrew dialysis. Seventy-six of a random sample of 214 (36%) primary care physicians returned questionnaires describing their practice experience in 1995 with patients with advanced chronic renal failure. The nephrologists withdrew dialysis from 60 of 822 (7%) patients. Academic nephrologists who had received education in the ethics and law of stopping dialysis withdrew it from a greater percentage of patients than those in private practice (12% v 6%; P = 0.009). Patients who were withdrawn more often resided in nursing homes (37% v 2%; P < 0.0001). Twenty-one patients (37%) lacked decision-making capacity at the time the decision was made to withdraw dialysis. Advance directives were available for 13 of the 21 (62%) patients: eight of the 10 treated by academic nephrologists and five of the 11 treated by private practice nephrologists. Academic nephrologists found advance directives to be helpful in decision making to withdraw dialysis of incapacitated patients more often than nephrologists in private practice (70% v 9%; P = 0.004). Nephrologists withheld dialysis from 25 of 357 (7%) ESRD patients compared with 42 of 193 (22%) withheld by primary care physicians (P < 0.001). In deciding not to refer a patient for a dialysis evaluation, 25% of primary care physicians did not consult a nephrologist; 60% cited age as a reason not to refer. These findings suggest that dialysis decision making might be improved by educating nephrologists about the ethics and law of withdrawing dialysis and about how to implement successfully advance care planning so that advance directives will be present and helpful when decisions need to be made for incapacitated dialysis patients. Education of primary care physicians about when to refer patients with chronic renal failure for a dialysis evaluation might also result in more referrals for patients who will benefit from dialysis.

Withdrawal and withholding of life support in the intensive care unit: a comparison of teaching and community hospitals. The Southwestern Ontario Critical Care Research Network

OBJECTIVES

To compare the incidence of withdrawal or withholding of life support (WD/WHLS), and to identify similarities and differences in the process of the withdrawal of life support (WDLS) between teaching and community hospitals' intensive care units (ICUs).

DESIGN

Prospective cohort study, with some data obtained by retrospective chart review.

SETTING

The ICUs of three teaching hospitals and six community hospitals.

PATIENTS

All patients who died in these nine ICUs over a 6-mo period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data on admitting diagnosis, cause of death, mode of death (death despite active treatment, withdrawal or withholding of life support), those initiating and involved in WDLS, and modalities of life support withdrawn were gathered for patients dying in the ICU over a 6-mo period. One hundred sixty patients in community hospitals and 292 in teaching hospitals died in their respective ICUs over the 6-mo period. We found a difference in the distribution of mode of death between community hospitals and teaching hospitals, resulting from a greater proportion of patients dying as a result of withholding life support in community hospitals (11.9% vs. 3.8% withheld, respectively, p = .004). Among the six community hospitals and three teaching hospitals, we found a difference in the proportion of patients dying despite active treatment compared with those dying as a result of WD/WHLS (p = .042 and p = .044, respectively). Initiation of WDLS by physicians was more frequent at teaching hospitals (81% vs. 61%, p = .0005), while families more commonly initiated WDLS at community hospitals (34% vs. 19%, p = .005). A greater proportion of patients in teaching hospitals were receiving mechanical ventilation (99% vs. 89%) and vasopressors (76% vs. 65%) before WDLS. Similar proportions had mechanical ventilation withdrawn (68% and 74%, community hospitals and teaching hospitals, respectively), while there was a trend for fewer patients in community hospitals to have vasopressors withdrawn (56% vs. 70%, p = .082). The time to death after WDLS had begun was longer in community hospitals compared with teaching hospitals (0.74 +/- 1.38 days vs. 0.27 +/- 0.79 [SD] days, p = .0028).

CONCLUSIONS

The incidence of WD/WHLS was similar in community hospitals and teaching hospitals; however, withholding of life support was more common in community hospitals. The process of WDLS appears to differ between community hospitals and teaching hospitals.

A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay

OBJECTIVE

To assess the effect of proactive ethics consultation on documented patient care communications and on decisions regarding high-risk intensive care unit (ICU) patients.

DESIGN

Prospective, controlled study.

PATIENTS

Ninety-nine ICU patients treated with >96 hrs of continuous mechanical ventilation.

INTERVENTIONS

Three groups were compared: a) a baseline group enrolled in the study prior to the establishment of the hospital's ethics consultation service; b) a control group where ethics consultation was at the option of the care team; and c) a treatment group where the ethics service intervened proactively after patients received >96 hrs of continuous mechanical ventilation. Patient care planning, for subjects in the proactive group, was reviewed with physicians and with the care team using a standardized set of prompting questions designed to focus discussion of key decision-making and communication issues for critically and terminally ill patients. Issues and concerns were identified and action strategies were suggested to those in charge of the patient's care. Formal ethics consultation, using a patient care conference model, was made available upon request.

MEASUREMENTS AND MAIN RESULTS

Post discharge chart reviews of the three groups indicated no statistically significant differences on important demographic variables including age, gender, and acuity. Comparisons of survivors and nonsurvivors for the three groups indicated, at statistically significant levels, more frequent and documented communications, more frequent decisions to forego life-sustaining treatment, and reduced length of stay in the ICU for the proactive consultation group.

CONCLUSION

Proactive ethics consultation for high-risk patient populations offers a promising approach to improving decision-making and communication and reducing length of ICU stay for dying patients.

Retrospective study of doctors' "end of life decisions" in caring for mentally handicapped people in institutions in The Netherlands

OBJECTIVES

To gain insight into the reasons behind and the prevalence of doctors' decisions at the end of life that might hasten a patient's death ("end of life decisions") in institutions caring for mentally handicapped people in the Netherlands, and to describe important aspects of the decisions making process.

DESIGN

Survey of random sample of doctors caring for mentally handicapped people by means of self completed questionnaires and structured interviews.

SUBJECTS

89 of the 101 selected doctors completed the questionnaire. 67 doctors had taken an end of life decision and were interviewed about their most recent case.

MAIN OUTCOME MEASURES

Prevalence of end of life decisions; types of decisions; characteristics of patients; reasons why the decision was taken; and the decision making process.

RESULTS

The 89 doctors reported 222 deaths for 1995. An end of life decision was taken in 97 cases (44%); in 75 the decision was to withdraw or withhold treatment, and in 22 it was to relieve pain or symptoms with opiates in dosages that may have shortened life. In the 67 most recent cases with an end of life decision the patients were mostly incompetent (63) and under 65 years old (51). Only two patients explicitly asked to die, but in 23 cases there had been some communication with the patient. In 60 cases the doctors discussed the decision with nursing staff and in 46 with a colleague.

CONCLUSIONS

End of life decisions are an important aspect of the institutionalised care of mentally handicapped people. The proportion of such decisions in the total number of deaths is similar to that in other specialties. However, the discussion of such decisions is less open in the care of mental handicap than in other specialties. Because of distinctive features of care in this specialty an open debate about end of life decisions should not be postponed.

Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995

BACKGROUND

In 1991 a new procedure for reporting physician-assisted deaths was introduced in the Netherlands that led to a tripling in the number of reported cases. In 1995, as part of an evaluation of this procedure, a nationwide study of euthanasia and other medical practices concerning the end of life was begun that was identical to a study conducted in 1990.

METHODS

We conducted two studies, the first involving interviews with 405 physicians (general practitioners, nursing home physicians, and clinical specialists) and the second involving questionnaires mailed to the physicians attending 6060 deaths that were identified from death certificates. The response rates were 89 percent and 77 percent, respectively.

RESULTS

Among the deaths studied, 2.3 percent of those in the interview study and 2.4 percent of those in the death-certificate study were estimated to have resulted from euthanasia, and 0.4 percent and 0.2 percent, respectively, resulted from physician-assisted suicide. In 0.7 percent of cases, life was ended without the explicit, concurrent request of the patient. Pain and symptoms were alleviated with doses of opioids that may have shortened life in 14.7 to 19.1 percent of cases, and decisions to withhold or withdraw life-prolonging treatment were made in 20.2 percent. Euthanasia seems to have increased in incidence since 1990, and ending of life without the patient's explicit request to have decreased slightly. For each type of medical decision except those in which life-prolonging treatment was withheld or withdrawn, cancer was the most frequently reported diagnosis.

CONCLUSIONS

Since the notification procedure was introduced, end-of-life decision making in the Netherlands has changed only slightly, in an anticipated direction. Close monitoring of such decisions is possible, and we found no signs of an unacceptable increase in the number of decisions or of less careful decision making.

Limitation of life support: frequency and practice in a London and a Cape Town intensive care unit

OBJECTIVES

To examine the frequency of limiting (withdrawing and withholding) therapy in the intensive care unit (ICU), the grounds for limiting therapy, the people involved in the decisions, the way the decisions are implemented and the patient outcome.

DESIGN

Prospective survey. Ethical approval was obtained.

SETTING

ICUs in tertiary centres in London and Cape Town.

PATIENTS

All patients who died or had life support limited.

INTERVENTIONS

Data collection only.

RESULTS

There were 65 deaths out of 945 ICU discharges in London and 45 deaths out of 354 ICU discharges in Cape Town. Therapy was limited in 81.5% and 86.7% respectively (p = 0.6) of patients who died. The mean ages of patients whose therapy was limited were 60.2 years and 51.9 years (p = 0.014) and mean APACHE II scores 18.5 and 22.6 (p = 0.19) respectively. The most common reason for limiting therapy in both centres was multiple organ failure. Both medical and nursing staff were involved in most decisions, which were only implemented once wide consensus had been reached and the families had accepted the situation. Inotropes, ventilation, blood products, and antibiotics were most commonly withdrawn. The mean time from admission to the decision to limit therapy was 11.2 days in London and 9.6 days in Cape Town. The times to outcome (death in all patients) were 13.2 h and 8.1 h respectively.

CONCLUSIONS

Withdrawal of therapy occurred commonly, most often because of multiple organ failure. Wide consensus was reached before a decision was made, and the time to death was generally short.

Community attitudes on the family of issues surrounding the death of terminal patients

In two studies, respondents made recommendations for the medical treatment of a terminally ill elderly woman. The woman was or was not experiencing intractable pain, and had requested either heroic medical efforts or euthanasia. Respondents' recommendations were influenced by both the specific wishes of the patient and the pain the person was experiencing. However, participants were not completely swayed by the patient's wishes: only about half of the sample recommended euthanasia even when the patient was in intractable pain and had requested death; also, many subjects would not resuscitate the patient whose heart or lungs failed, even though she had requested heroic measures. Respondent attitudes toward euthanasia predicted recommendations in the expected directions. We suggest that there is less dissent on the issues that arise for medical treatments at the end of life than has been widely assumed.

Medical specialists prefer to withdraw familiar technologies when discontinuing life support

OBJECTIVE

To assess how members of different specialties vary in their decisions about which form of life support to withdraw. The hypothesis was that each specialty would be more comfortable withdrawing its "own" form of life support relative to other forms and other specialties.

DESIGN

Mail survey.

SETTING

24 medical centers.

PARTICIPANTS

225 specialists in six specialties and 225 comparison physicians randomly matched according to percentage of time devoted to clinical practice.

MEASUREMENTS

The six specialties were linked with six life-sustaining technologies related to their special expertise: 1) pulmonologists with mechanical ventilation, 2) nephrologists with hemodialysis, 3) gastroenterologists with tube feedings, 4) hematologists with blood products, 5) cardiologists with intravenous vasopressors, and 6) infectious disease specialists with antibiotics. The subjects ranked different forms of life support in the order in which they would prefer to withdraw them. They also expressed their preferences in response to hypothetical clinical vignettes.

RESULTS

In five of the six specialties, the specialists had a relative preference for withdrawing their "own" form of life support, compared with the preferences of the comparison physicians. Overall, the physicians tended to prefer withdrawing a form of life support closely linked with their own specialty.

CONCLUSIONS

Just as some specialist physicians tend to reach for different technologies first in treating patients, they also tend to reach for different technologies first when ceasing treatment. Specialists' preferences for different ways to withdraw life support not only may reflect a special understanding of the limits of certain technologies, but also may reveal how ingrained are physicians' patterns of practice.

Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: conflicts between physicians' practices and patients' wishes

We surveyed a national sample of 879 physicians practicing in adult intensive care units in the United States, in order to determine their practices with regard to limiting life-sustaining medical treatment, and particularly their decisions to continue or forgo life support without the consent or against the wishes of patients or surrogates. Virtually all of the respondents (96%) have withheld and withdrawn life-sustaining medical treatment on the expectation of a patient's death, and most do so frequently in the course of a year. Many physicians continue life-sustaining treatment despite patient or surrogate wishes that it be discontinued (34%), and many unilaterally withhold (83%) or withdraw (82%) life-sustaining treatment that they judge to be futile. Some of these decisions are made without the knowledge or consent of patients or their surrogates, and some are made over their objections. We conclude that physicians do not reflexively accept requests by patients or surrogates to limit or continue life-sustaining treatment, but place these requests alongside a collection of other factors, including assessments of prognosis and perceptions of other ethical, legal, and policy guidelines. While debate continues about the ethical and legal foundations of medical futility, our results suggest that most critical care physicians are incorporating some concept of medical futility into decision making at the bedside.

The clinical management of dying patients receiving mechanical ventilation. A survey of physician practice

OBJECTIVE

Despite mechanical ventilation's widespread use, there is scant literature to guide the management of patients receiving mechanical ventilatory assistance who are foregoing life-sustaining treatment. This survey was conducted to characterize physician treatment of such patients.

DESIGN

Surveys were mailed to 513 randomly selected critical care physicians and returned by 308 (60 percent); 273 respondents were involved in ventilator management; all others were excluded.

PARTICIPANTS

Forty percent of respondents were internists, 28 percent were surgeons, 16 percent were pediatricians, and 11 percent were anesthesiologists; 85 percent of physicians were board eligible/certified in a critical care subspecialty.

RESULTS

Fifteen percent of respondents almost never withdrew ventilators from dying patients foregoing life-sustaining treatment; 37 percent did so less than half the time. Twenty-six percent of physicians believed there was a moral difference between withholding and withdrawing ventilators. Of physicians who withdrew ventilators, 33 percent preferred terminal weaning, 13 percent preferred extubation, and the remainder used both methods. Reasons for preferring extubation included the directness of the action (72 percent), family perceptions (34 percent), and patient comfort (34 percent). Reasons for preferring terminal weaning included patient comfort (65 percent), family perceptions (63 percent), and the belief that terminal weaning was less active (49 percent). Morphine and benzodiazepines were used frequently by 74 percent (morphine) and 53 percent (benzodiazepines) of physicians when withdrawing ventilators; 6 percent used paralytics at least occasionally.

CONCLUSIONS

There is significant variation in the care of dying patients receiving mechanical ventilatory assistance, with 15 percent of respondents almost never withdrawing ventilators from such patients. Two very different methods of ventilator withdrawal each have advocates, yet rationales of patient comfort and family perceptions are matters of individual experience, absent published studies. The occasional use of paralytics during ventilator withdrawal raises concern about current practice.

Modes of death in the pediatric intensive care unit: withdrawal and limitation of supportive care

OBJECTIVE

To determine the frequency of withdrawal or limitation of supportive care for children dying in a pediatric intensive care unit (ICU).

DESIGN

Retrospective review of medical records.

SETTING

Pediatric ICU in a tertiary care children's hospital.

PATIENTS

All children dying in the pediatric ICU over a 54-month period (n = 300).

INTERVENTIONS

Medical record review.

MEASUREMENTS AND MAIN RESULTS

Data recorded for each patient included diagnosis, mode of death, and whether the child was brain dead. Each patient was assigned to one of the following mode of death categories: brain dead; active withdrawal of supportive care (meaning removal of the endotracheal tube); failed cardiopulmonary resuscitation; allowed to die without cardiopulmonary resuscitation (do-not-resuscitate status). A total of 300 patients were identified. Diagnoses included postoperative congenital heart disease (n = 56), head trauma (n = 38), near-miss sudden infant death syndrome (n = 28), pneumonia (n = 22), sepsis (n = 21), near-drowning (n = 21), various anoxic insults (n = 20), multiple trauma (n = 17), and patients with other diagnoses (n = 77). Mode of death was active discontinuation of support in 95 (32%) patients, do-not-resuscitate status in 78 (26%), brain death in 70 (23%), and failed cardiopulmonary resuscitation in 57 (19%).

CONCLUSIONS

In a large, multidisciplinary pediatric ICU, the most common mode of death was active withdrawal of support. In addition, more than half (173/300, 58%) of children dying in the pediatric ICU underwent either active withdrawal or limitation (do-not-resuscitate status) of supportive care.