Withholding and withdrawing life support: national French prospective study

Introduction

Controversies still exists regarding indications of WII and WD, ethical similarity or difference between WH and WD, the way to withhold or to withdraw treatments and what should be the family implications in these decisions

Aim of the study

To evaluate the reality of withholding and withdrawing life support (WH and WD), the type of withheld and withdrawn treatments and the conditions leading to decisions to WH or WD.

Material and methods

113 French ICU participated to the study. The following data were collected for all the admitted ICU patients during a 2-month study period: age, sex, SAPS II, main diagnostic, previous chronic disease. In patients for whom WH or WD were indicated, additional data were recorded. The reasons to withheld or withdraw treatments and the type of WH or WD life support treatments were recorded.

Results

Treatments were withheld or withdrawn in 807 out 7309 (11%). WH and WD were indicated in 336 patients (4.6%) and 471 patients (6.4%) respectively. ICU patients undergoing WH or WD were older and had higher SAPS 2 than the remaining patients. Decisions of withhold or withdraw were more frequent in patients with previous chronic diseases or cardiac arrest before admission in ICU. Futility and the poor expected quality of life were the most frequently cited reason for WH or WD. Decision to not ventilate the patient was the most frequently reported withheld treatment (n = 214; 15%). Vasopressors were either not started or limited in their dosage in 196 patients (14%). The most frequently withdrawn life support treatment were vasopressors (19%). Extra-renal epuration was discontinued in 67 patients (7%). Lowering FiO₂ to 21% was indicated in 155 patients (14.5%), discontinued ventilation was ordered in 101 patients (9.4%) and extubation was performed only in 34 patients (3.1%). Withdrawal of hydration was rarely performed (n = 16; 1.5%). 1176 out of the 7309 (16.1%) included patients died. 628 out 1176 died (53%) after support was withheld or withdrawn. Most of the time WH or WD was decided by the medical team. A unique M.D. was involved in the decision in 37 (12%) of cases. Paramedic (nurses) opinions was taken in account for the decision in 482 (59.7%). Family was involved in the process in less than 50%.

Comments

The reality and the frequency of WH and WD life support treatments have been demonstrated in this large study involving an important number of French ICU.