title: The influence of access to a private attending physician on the withdrawal of life-sustaining therapies in the intensive care unit.
abstract: OBJECTIVE
  To assess the influence of patient access to a private attending physician on the withdrawal of life-sustaining therapies in a medical intensive care unit (ICU).
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  A university-affiliated teaching hospital.
  
  
  METHODS
  A total of 501 consecutive patients admitted to the medical ICU during a 5-month period.
  
  
  METHODS
  None
  
  
  RESULTS
  Among patients dying in the medical ICU, those without a private attending physician (n = 26) were statistically more likely to undergo the active withdrawal of life-sustaining therapies than patients with a private attending physician (n = 87) (80.8% vs. 29.9%; relative risk = 2.70; 95% confidence interval = 1.86-3.92; p < .001). Despite having similar predicted mortality rates by Acute Physiology and Chronic Health Evaluation II score (60.5% +/- 27.0% vs. 66.1% +/- 21.3%; p = .280), patients dying in the medical ICU without a private attending physician had statistically shorter hospital and ICU lengths of stay, a shorter duration of mechanical ventilation, and fewer total hospital costs and charges compared with patients with access to a private attending physician. Multiple logistic regression analysis, controlling for severity of illness, demographic characteristics, and patient diagnoses, demonstrated that lack of access to a private attending physician (adjusted odds ratio = 23.10; 95% confidence interval = 9.10-58.57; p < .001) and the presence of a do-not-resuscitate order while in the ICU (adjusted odds ratio = 7.33; 95% confidence interval = 3.69-14.54; p = .004) were the only variables independently associated with the withdrawal of life-sustaining therapies before death.
  
  
  CONCLUSIONS
  Patients dying in a medical ICU setting without access to a private attending physician are more likely to undergo the active withdrawal of life-sustaining therapies before death than patients with a private attending physician. Health care providers should be aware of possible variations in the practice of withdrawal of life-sustaining therapies in their ICUs based on this patient characteristic.
authors.affiliation: Department of Internal Medicine, Washington University School of Medicine, St Louis, MO, USA.
authors.forename: M H
authors.initials: MH
authors.lastname: Kollef
authors.forename: S
authors.initials: S
authors.lastname: Ward
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005066:Euthanasia, Passive; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D016304:Hospitals, Private / Q000706:statistics & numerical data; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007902:Length of Stay; D008020:Life Support Care; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010819:Physician's Role; D010817:Physician-Patient Relations; D011331:Private Practice / Q000706:statistics & numerical data*; D011446:Prospective Studies; D016414:Resuscitation Orders