title: Private attending physician status and the withdrawal of life-sustaining interventions in a medical intensive care unit population.
abstract: OBJECTIVE
  To assess the influence of private attending physician status on the withdrawal of life-sustaining interventions among patients dying within a medical intensive care unit (ICU).
  
  
  METHODS
  Retrospective cohort analysis.
  
  
  METHODS
  An academic tertiary care center.
  
  
  METHODS
  One hundred fifty-nine consecutive patient deaths occurring in the medical ICU during a 12-month period.
  
  
  METHODS
  None.
  
  
  RESULTS
  Withdrawal of life-sustaining interventions (i.e., mechanical ventilation, dialysis, and/or vasopressors), duration of mechanical ventilation, length of intensive care unit stay, medical care costs, and patient charges were recorded. Life sustaining interventions were actively withdrawn from 69 (43.4%) patients prior to death. Patients without a private attending physician were significantly more likely to undergo the withdrawal of life-sustaining interventions compared with patients having a private attending physician (odds ratio = 2.5; 95% confidence interval = 1.8, 3.6, respectively; p = .005). A correlation was found between the possession of private health insurance and private attending physician status (r2 = .39, p < .001). Multiple logistic regression analysis was subsequently used to control for demographic factors and severity of illness. Three independent predictors for the withdrawal of life-sustaining interventions were identified in this patient cohort (p < .05) having a planned therapeutic trial of life-sustaining interventions outlined in the medical record (adjusted odds ratio 9.4; 95% confidence interval = 5.6 to 15.6; p < .001); lack of a private attending physician (adjusted odds ratio = 4.4; 95% confidence interval = 2.9 to 6.5; p < .001); and the presence of clearly defined advance directives regarding patient preferences for medical care (adjusted odds ratio = 3.6; 95% confidence interval = 2.3 to 5.7; p. = .005). Patients with private attending physicians had significantly greater medical care costs and medical care charges compared with patients without a private attending physician.
  
  
  CONCLUSIONS
  Among patients dying within a medical ICU, those patients without a private attending physician are more likely to undergo the active withdrawal of life-sustaining interventions.
authors.affiliation: Pulmonary and Critical Care Division, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA.
authors.forename: M H
authors.initials: MH
authors.lastname: Kollef
mesh_terms: D018806:APACHE; D000368:Aged; D015331:Cohort Studies; D004992:Ethics, Medical; D005066:Euthanasia, Passive; D005260:Female; D006801:Humans; D007348:Insurance, Health; D007362:Intensive Care Units / Q000191:economics; D007902:Length of Stay / Q000191:economics; D008021:Life Support Systems; D008297:Male; D008875:Middle Aged; D012044:Regression Analysis; D016414:Resuscitation Orders; D012189:Retrospective Studies