title: Withdrawal of life-sustaining treatment: patient and proxy agreement: a secondary analysis of "contracts, covenants, and advance care planning".
abstract: BACKGROUND
  Families of critically ill patients often make difficult decisions related to end-of-life (EOL) care including the withdrawal of life-sustaining therapies.
  
  
  OBJECTIVE
  This study explored patient and proxy decisions related to mechanical ventilator withdrawal in scenarios characterizing 3 distinct disease trajectories (cancer, stroke, and heart failure [HF]) with different prognoses. The relationship between patient directives, modification of directives, prognosis, trust, and EOL decisions were examined.
  
  
  METHODS
  This secondary analysis of data obtained in the "Contracts, Covenants, and Advance Care Planning" study included a sample of 110 subjects with 50 patient-proxy pairs. Patient and proxy agreement was assessed in response to questions regarding mechanical ventilator withdrawal while considering directives or modification of directives in 3 different scenarios.
  
  
  RESULTS
  Patient and proxy agreement ranged from 48% (n = 24 pairs) to 94% (n = 47 pairs). Agreement was lowest in HF (uncertain prognosis) when the directive indicated "do nothing" or "did not indicate any preference." Modified directives yielded 48% (n = 24 pairs) to 84% (n = 42 pairs) agreement. Changing directives from "do nothing" to "more hopeful" in HF (uncertain prognosis) had the highest agreement among modified scenarios. Despite wide variability in agreement, patients reported a high level of trust in their proxies' decisions.
  
  
  CONCLUSIONS
  This study highlighted differences in patient and proxy agreement about withdrawal of mechanical ventilation. Critical care nurses provide a key role in supporting EOL decisions. Encouraging ongoing communication about preferences and understanding the role of disease process and prognosis in decision making are paramount. Future research needs to explore factors that may improve patient and proxy agreement in EOL decisions and ways critical care nurses can support patients and proxies in these decisions, ultimately improving EOL care.
authors: Katherine A. Hinderer, PhD, RN, CCRN, CNE, is assistant professor in the Department of Nursing at Salisbury University, Maryland. Erika Friedmann, PhD, is professor of organizational systems and adult health at the University of Maryland School of Nursing, Baltimore. Joseph J. Fins, MD, MACP, is chief of the Division of Medical Ethics; The E. William Davis, Jr, MD, professor of medical ethics and professor of medicine, health care policy and research, and medicine in psychiatry at Weill Cornell Medical College; and director of medical ethics and attending physician at the New York Presbyterian-Weill Cornell Medical Center, New York.
authors: Katherine A
authors: KA
authors: Hinderer
authors: Erika
authors: E
authors: Friedmann
authors: Joseph J
authors: JJ
authors: Fins
mesh_terms: D032722:Advance Care Planning; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019727:Proxy; D012121:Respiration, Artificial; D012494:Sampling Studies; D028761:Withholding Treatment