Decisions and Communication About Life Support in Intensive Care Unit
Embargo until
2014-12-01
Date
2013-11-11
Authors
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Publisher
Johns Hopkins University
Abstract
Most elderly Americans die as a result of chronic, incurable diseases. As the
burden of their symptoms become difficult to manage in the last weeks of life, many are admitted to ICUs. The majority of ICU patients cannot participate in medical decision-making. This leaves physicians and family members to decide whether life supporting interventions are an appropriate means of achieving the
person’s goals of care, or a prolongation of the dying process. This dissertation contains three inquiries into how such decisions are made using data from a longitudinal cohort study of patients with acute lung injury, and a randomized trial among academic intensivists.
The first inquiry scrutinizes the role of patient age. Our findings indicate
the increased rate of limitations in life support among older patients is not a
result of greater organ dysfunction following ICU admission.
Next we describe the timing of decisions to limit life support. In medical ICUs, the rate of decisions for patients without improvement in organ function tripled in the first three days following acute lung injury (ALI) onset. For 5 days after ALI onset, limitations were significantly more common in medical than surgical ICUs. In all ICUs, persistent organ failure was associated with an increase in the rate of limitations independent of the absolute magnitude of organ dysfunction.
Finally, we performed a scenario-based, randomized trial of 630 academic intensivists to estimate the effect of 1) patient values as expressed by family members, and 2) requiring intensivists to record a 3-month, functional prognosis on their intent to discuss withdrawal of life support in a hypothetical family meeting as compared to a control group of intensivists. Patient values had no
impact on intensivists’ intentions, but requiring a functional prognosis
substantially increased the intention to discuss withdrawing life support.
Description
Keywords
Decision Making, Intensive Care, Resuscitation Orders, Prognosis, Withholding Treatment, Life Support Care