title: The sequence of withdrawing life-sustaining treatment from patients.
abstract: OBJECTIVE
  To describe the observed sequence of withdrawal of eight different forms of life-sustaining treatment and to determine whether aspects of those treatments determine the order of withdrawal.
  
  
  METHODS
  We observed 211 consecutive patients dying in four midwestern US hospitals from whom at least one of eight specific life-sustaining treatments was or could have been withdrawn. We used a parametric statistical technique to explain the order of withdrawal based on selected characteristics of the forms of life support, including cost, scarcity, and discomfort.
  
  
  RESULTS
  The eight forms of life support were withdrawn in a distinct sequence. From earliest to latest, the order was blood products, hemodialysis, vasopressors, mechanical ventilation, total parenteral nutrition, antibiotics, intravenous fluids, and tube feedings (P <0.0001). The sequence was almost identical to that observed in a previous study based on hypothetical scenarios. Forms of life support that were perceived as more artificial, scarce, or expensive were withdrawn earlier.
  
  
  CONCLUSIONS
  The preference for withdrawing some forms of life-sustaining treatments more than others is associated with intrinsic characteristics of these treatments. Once the decision has been made to forgo life-sustaining treatment, the process remains complex and appears to target many different goals simultaneously.
authors.affiliation: Veterans Affairs Medical Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia 19104-6218, USA.
authors.forename: D A
authors.initials: DA
authors.lastname: Asch
authors.forename: K
authors.initials: K
authors.lastname: Faber-Langendoen
authors.forename: J A
authors.initials: JA
authors.lastname: Shea
authors.forename: N A
authors.initials: NA
authors.lastname: Christakis
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D005260:Female; D015276:Health Care Rationing; D006764:Hospitals, Community; D006785:Hospitals, University; D006801:Humans; D008020:Life Support Care / Q000191:economics / Q000592:standards*; D008297:Male; D018447:Medical Futility; D008875:Middle Aged; D008910:Minnesota; D008923:Missouri; D013727:Terminal Care / Q000191:economics / Q000592:standards*; D028761:Withholding Treatment