Withdrawal of Life-Sustaining Measures

Most patients who die in ICU and acute-care settings do so after a decision to limit life-sustaining treatments. Physicians have an important responsibility to improve the process by which life-sustaining treatments are withheld or withdrawn. Although little empiric evidence is available to guide clinicians in the practical aspects of withdrawing life-sustaining treatments, ICU physicians should thoroughly understand the goals of withdrawing life-sustaining treatments (to remove all treatments no longer desired or indicated while ensuring patient comfort during the process) and should develop expertise in withdrawing life-sustaining treatments in order to minimize patient symptoms and support the family.

Withdrawal of life-sustaining treatments is a clinical procedure; physicians must have the same preparation and expectation of its quality as for other procedures. The rationale for the decision to withdraw life support should be documented in the medical record. Several topics should be discussed with families, including explaining how interventions will be withdrawn, how the patient’s comfort will be ensured, the patient’s expected length of survival, and family or patient preferences about other aspects of end-of-life care. An explicit plan for performing the procedure 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 reasons for increasing sedation or analgesia; and outcomes should be evaluated to improve the quality of future care.

Once a decision is made and a time is set to withdraw life-sustaining treatments, the course and timing of withdrawal should be determined by the potential for patient discomfort as treatment is stopped. Although time should be provided for family to say goodbye, the only rationale for tapering life-sustaining treatment is to allow time to meet the patient’s needs for symptom control. Vasopressors, antibiotics, nutrition, or most other critical care treatments can be discontinued immediately, without tapering. Mechanical ventilation is one of the few life-support treatments for which abrupt termination can lead to discomfort; consequently, physicians have a responsibility to develop an approach to terminal ventilator discontinuation that ensures patient comfort. A protocol that explicitly details an approach to withdrawal of life support in the ICU, including mechanical ventilation, has been associated with high ratings of clinician satisfaction and may help improve the quality of care, especially in settings where physicians are not familiar with withdrawal of life support or where there is significant practice variation. A sample protocol devised for withdrawal of mechanical ventilation is shown in Table 1. Physicians also should inform families that, while death is expected after withdrawal of support, it may not be certain and the timing can vary.

Any protocol for withholding life-sustaining treatments should include an explicit protocol for sedation and analgesia during this procedure. Such a protocol, carefully developed and implemented, has been associated with high levels of physician and nurse satisfaction, as well as with increased use of opiates and benzodiazepines for some patients without change in time from ventilator withdrawal to death. Furthermore, higher doses of opiates and benzodiazepines in the context of withdrawing mechanical ventilation has been shown to be associated with no change or an actual increase in time from withdrawal of mechanical ventilation to death, suggesting that these drugs can be used to provide for patient comfort without hastening death.

• IMV = intermittent mandatory ventilation;
• PS = pressure support;
• Fio₂ = fraction of inspired oxygen;
• PEEP = positive end-expiratory pressure;
• CPAP =continuous positive airway pressure.