Respiratory support withdrawal in intensive care units: Families, physicians and nurses views on two hypothetical clinical scenarios

Unidade de Terapia Intensiva, Centro de Tratamento e Pesquisa Hospital AC Camargo, Rua Prof, Antônio Prudente, 211 - São Paulo, SP, Brazil CEP 01509-900.
Critical care (London, England) (Impact Factor: 4.48). 12/2010; 14(6):R235. DOI: 10.1186/cc9390
Source: PubMed


Evidence suggests that dying patients' physical and emotional suffering is inadequately treated in intensive care units. Although there are recommendations regarding decisions to forgo life-sustaining therapy, deciding on withdrawal of life support is difficult, and it is also difficult to decide who should participate in this decision.
We distributed a self-administered questionnaire in 13 adult intensive care units (ICUs) assessing the attitudes of physicians and nurses regarding end-of-life decisions. Family members from a medical-surgical ICU in a tertiary cancer hospital were also invited to participate. Questions were related to two hypothetical clinical scenarios, one with a competent patient and the other with an incompetent patient, asking whether the ventilator treatment should be withdrawn and about who should make this decision.
Physicians (155) and nurses (204) of 12 ICUs agreed to take part in this study, along with 300 family members. The vast majority of families (78.6%), physicians (74.8%) and nurses (75%) want to discuss end-of-life decisions with competent patients. Most of the physicians and nurses desire family involvement in end-of-life decisions. Physicians are more likely to propose withdrawal of the ventilator with competent patients than with incompetent patients (74.8% × 60.7%, P = 0.028). When the patient was incompetent, physicians (34.8%) were significantly less prone than nurses (23.0%) and families (14.7%) to propose decisions regarding withdrawal of the ventilator support (P < 0.001).
Physicians, nurses and families recommended limiting life-support therapy with terminally ill patients and favored family participation. In decisions concerning an incompetent patient, physicians were more likely to maintain the therapy.

11 Reads
  • Source
    • "Thus, considerations for these patients were presumed to be those without DNR consent. However, the adaptation of PMV incidence in our study should be cautious because life-supporting treatment would be allowed to be withdrawn in other countries under certain circumstances [36,37]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: This study is aimed at determining incidence, survival rate, life expectancy, quality-adjusted life expectancy (QALE), and prognostic factors in cancer patients with different organ-systems undergoing prolonged mechanical ventilation (PMV). We used data from the National Health Insurance Research Database (NHIRD) of Taiwan, from 1998 to 2007, linked with the National Mortality Registry to ascertain mortality. Subjects who received PMV, defined as having undergone mechanical ventilation continually for longer than 21 days, were enrolled. The incidences of cancer patients requiring PMV were calculated with the exception of multiple cancers. The life expectancies and QALE of different types of cancer were estimated. Quality of life data were taken from a sample of 142 patients under PMV. A multivariable proportional hazard model was constructed to assess the effect of different prognostic factors, including age, gender, types of cancer, metastasis, comorbidities, and hospital levels. Among 9011 cancer patients receiving mechanical ventilation for more than seven days, 5138 undergoing PMV revealed a median survival of 1.37 (interquartile range [IQR], 0.50-4.57) months and a one-year survival rate of 14.3% (95% confidence interval [CI], 13.3-15.3%). The incidence of PMV was 10.4 per 100 ICU admissions. Head and neck cancer patients seemed to survive the longest. The overall life expectancy was 1.21 years with estimated QALE ranging from 0.17 to 0.37 quality-adjusted life years for patients with poor and partial cognition, respectively. Cancer of liver (hazard ratio [HR], 1.55; 95%CI, 1.34-1.78), lung (HR, 1.45; 95%CI, 1.30-1.41), and metastasis (HR, 1.53; 95%CI, 1.42-1.65) independently were found to predict shorter survival. Cancer patients requiring PMV had poor long-term outcomes. Palliative care should be considered early in these patients, especially when metastasis has occurred.
    Critical care (London, England) 07/2013; 17(4):R144. DOI:10.1186/cc12823 · 4.48 Impact Factor
  • Source
    • "In a recent issue of Critical Care, Fumis and Deheinzelin [1] evaluated the attitudes regarding end-of-life (EOL) decisions of physicians, nurses and family members in 13 Brazilian ICUs. Participants were asked whether mechanical ventilation should be withdrawn from two hypothetical terminally ill patients (one incompetent and another competent) and who should be involved in the decision-making process. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Disagreements between the perceptions of nurses and physicians regarding end-of-life (EOL) decisions are frequent. In a survey carried out in 13 Brazilian ICUs, Fumis and Deheinzelin reported that the majority of nurses, physicians and family members are in favor of limiting life-sustaining therapies in terminally ill patients and that such decisions should involve the ICU team, patients and family members. However, they also observed significant differences among the attitudes when faced with an incompetent patient. The present commentary evaluates the potential implications of the study results, contextualizing with the current scenario surrounding EOL care in Brazil.
    Critical care (London, England) 01/2011; 15(1):110. DOI:10.1186/cc9962 · 4.48 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: We studied the frequency of withdrawal of mechanical ventilation (MV) and/or vasoactive agents (VAs), the time until death, and dosages of opioids and sedatives in a Dutch academic intensive care unit (ICU), and compared these practices with international observations in this field. Retrospective data were collected from the electronic and paper files of all patients who died after withdrawal of treatment in a Dutch ICU between October 2006 and February 2007. In this period, 471 patients were admitted to the ICU, of whom 88 died (18%). In 60 of these patients (68%), MV and/or VAs were withdrawn. This group represented 13% of the total ICU population. Of the 60 patients for whom MV and/or VAs were withdrawn, 54 (90%) died after withdrawal of MV (with or without VAs). Six (10%) died after withdrawal of VAs only, 33 (55%) after withdrawal of MV in combination with VAs, and 21 (35%) after withdrawal of MV only. Death occurred after withdrawal of MV in combination with VAs after a median of 30 minutes (interquartile range [IQR], 10-195 minutes). When only MV was discontinued, the median time until death was 50 minutes (IQR, 15-530 minutes). When only VAs were withdrawn, patients died after a median of 45 minutes (IQR, 20-715 minutes). Ten patients (17%) did not receive opioids or sedatives in their last hours. Fifty patients received opioids in their last hours. Fentanyl, with a median dosage at time of death of 100 μg/h, was the most frequently used opioid. Forty (80%) of the 50 patients mentioned above received some kind of sedative until death. In the MV withdrawal group, 34 of the 54 patients (63%) received sedatives in the last hours of their lives: 16 (27%) received midazolam (median, 10 mg/h), 12 (22%) propofol (median, 160 mg/h), and 6 (11%) lorazepam (2.0 mg/h). Sedatives were administered to all patients in whom only VAs were withdrawn. Dutch patients who die in the ICU, or die after discharge from the ICU, die after MV and/or VAs are withdrawn. When treatments are withdrawn, death follows within 1 hour in most patients, which is a reflection of the severity of illnesses. At least 80% of patients receive opioids, and 67% receive sedatives until death. Fentanyl is the most used opioid, whereas midazolam is the most used sedative. Dosages of opioids and sedatives did not significantly exceed the ranges described as usual in the international literature.
    Anesthesia and analgesia 02/2011; 112(3):628-34. DOI:10.1213/ANE.0b013e31820ad4d9 · 3.47 Impact Factor
Show more

Preview (2 Sources)

11 Reads
Available from