title: Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers.
abstract: OBJECTIVE
  Many intensive care unit (ICU) physicians have withdrawn life-support from a patient who lacked decision-making capacity and a surrogate decision-maker, yet little is known about the decision-making practices for these patients. We sought to determine how often such patients are admitted to the ICU of a metropolitan hospital and how end-of-life decisions are made for them.
  
  
  METHODS
  Prospective, observational cohort study.
  
  
  METHODS
  Consecutive adult patients admitted to the medical ICU of a metropolitan West Coast hospital during a 7-month period in 2003 to 2004.
  
  
  METHODS
  Attending physicians completed a questionnaire about the decision-making process for each patient for whom they considered limiting life-support who lacked decisional capacity and a legally recognized surrogate decision-maker.
  
  
  RESULTS
  Of the 303 patients admitted during the study period, 49 (16%; 95% confidence interval [CI], 12-21%) lacked decision-making capacity and a surrogate during the entire ICU stay. Compared with all other ICU patients, these patients were more likely to be male (88% vs. 69%; p = .002), white (42% vs. 23%; p = .028), and > or =65 yrs old (29% vs. 13%; p = .007). Physicians considered withholding or withdrawing treatment from 37% (18) of the 49 patients who lacked both decision-making capacity and a surrogate decision-maker. For 56% (10) of these 18 patients, the opinion of another attending physician was obtained; for 33% (6 of 18), the ICU team made the decision independently, and for 11% (2 of 18), the input of the courts or the hospital ethics committee was obtained. Overall, 27% of deaths (13 of 49) during the study period were in incapacitated patients who lacked a surrogate (95% CI, 15-41%).
  
  
  CONCLUSIONS
  Sixteen percent of patients admitted to the medical ICU of this hospital lacked both decision-making capacity and a surrogate decision-maker. Decisions to limit life support were generally made by physicians without judicial or institutional review. Further research and debate are needed to develop optimal decision-making strategies for these difficult cases.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA.
authors.forename: Douglas B
authors.initials: DB
authors.lastname: White
authors.forename: J Randall
authors.initials: JR
authors.lastname: Curtis
authors.forename: Bernard
authors.initials: B
authors.lastname: Lo
authors.forename: John M
authors.initials: JM
authors.lastname: Luce
mesh_terms: D000328:Adult; D017677:Age Distribution; D016638:Critical Illness; D003657:Decision Making; D028741:Ethics Committees, Clinical; D005260:Female; D006801:Humans; D007258:Informed Consent; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D016743:Mental Competency; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D016414:Resuscitation Orders; D017678:Sex Distribution; D011795:Surveys and Questionnaires; D020458:Third-Party Consent; D014481:United States; D028761:Withholding Treatment