Withdrawal of medical treatment in the ICU. A cohort study of 318 cases during 1994-2000.
BACKGROUND
Many deaths in intensive care occur after life support has been withdrawn or withheld. In Sweden there are no guidelines for the withholding or withdrawal of life-sustaining treatments, and information on the frequency of such decisions is scarce. Open and conscious accounts of crucial standpoints in theses decisions are important. The aim of this study was to determine the incidence of decisions to withdraw medical therapy in a Swedish, general intensive care unit (ICU), the underlying reasons and outcomes.


METHODS
In this historical cohort study in a 10 bed ICU, we studied the records of the 3904 patients admitted during the period 1994-2000.


RESULTS
Medical therapy was withdrawn in 318 (8.1%) patients. During the study period, 466 patients died in the ICU, of which 191 (41.0%) had had a withdrawal decision. Of the 318 patients with a withdrawal decision followed up, 191 (60.1%) died in the ICU, 104 (32.7%) later on a general ward, and 23 (7.2%) were discharged alive from the hospital. The main reasons for withdrawing therapy were failure to respond to treatment in 119 (37%), poor prognosis of the acute disease in 119 (37%), poor prognosis of coexisting chronic disease in 62 (20%) and the patient's own request in 18 (6%) of the cases. The median time from ICU-admission to a withdrawal decision was 2.8 days. The median time from a withdrawal decision to death was 0.6 days (191 patients) in the ICU, 2.4 days (104 patients) in the general ward and 1.4 months (19 patients) for those dying after hospital discharge. In five cases a renewed evaluation was performed.


CONCLUSIONS
Medical therapy was withdrawn in the ICU in 8.1% of patients and the chief reasons were failure to respond to therapy or poor prognosis of the acute disease. Four patients were still alive five years later. The time interval from admission to a withdrawal decision was short.
Nolin
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Department of Anaesthesiology, Central Hospital, Kristianstad, Sweden. thomas.nolin@skane.se
Andersson
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D018806:APACHE; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003142:Communication; D003422:Critical Care / Q000941:ethics*; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D008021:Life Support Systems; D008297:Male; D008875:Middle Aged; D011640:Public Policy; D012189:Retrospective Studies; D013548:Sweden; D013997:Time Factors; D016896:Treatment Outcome; D028761:Withholding Treatment / Q000941:ethics / Q000706:statistics & numerical data*