Withdrawal and withholding of life support in the intensive care unit: A comparison of teaching and community hospitals

Abstract

Objectives: To compare the incidence of withdrawal or withholding of life support (WD/WHLS), and to identify similarities and differences in the process of the withdrawal of life support (WDLS) between teaching and community hospitals’ intensive care units (ICUs). Design: Prospective cohort study, with some data obtained by retrospective chart review. Setting: The ICUs of three teaching hospitals and six community hospitals. Patients: All patients who died in these nine ICUs over a 6-mo period. Interventions: None. Measurements and Main Results: Data on admitting diagnosis, cause of death, mode of death (death despite active treatment, withdrawal or withholding of life support), those initiating and involved in WDLS, and modalities of life support withdrawn were gathered for patients dying in the ICU over a 6-mo period. One hundred sixty patients in community hospitals and 292 in teaching hospitals died in their respective ICUs over the 6-mo period. We found a difference in the distribution of mode of death between community hospitals and teaching hospitals, resulting from a greater proportion of patients dying as a result of withholding life support in community hospitals (11.9% vs. 3.8% withheld, respectively, p = .004). Among the six community hospitals and three teaching hospitals, we found a difference in the proportion of patients dying despite active treatment compared with those dying as a result of WD/WHLS (p = .042 and p = .044, respectively). Initiation of WDLS by physicians was more frequent at teaching hospitals (81% vs. 61%, p = .0005), while families more commonly initiated WDLS at community hospitals (34% vs. 19%, p = .005). A greater proportion of patients in teaching hospitals were receiving mechanical ventilation (99% vs. 89%) and vasopressors (76% vs. 65%) before WDLS. Similar proportions had mechanical ventilation withdrawn (68% and 74%, community hospitals and teaching hospitals, respectively), while there was a trend for fewer patients in community hospitals to have vasopressors withdrawn (56% vs. 70%, p = .082). The time to death after WDLS had begun was longer in community hospitals compared with teaching hospitals (0.74 +/- 1.38 days vs. 0.27 +/- 0.79 [SD] days, p = .0028). Conclusions: The incidence of WD/WHLS was similar in community hospitals and teaching hospitals; however, withholding of life support was more common in community hospitals. The process of WDLS appears to differ between community hospitals and teaching hospitals. (Crit Care Med 1998; 26:245-251) Withdrawal or withholding of life support (WD/WHLS) are the most common modes of death in intensive care units (ICUs) of academic institutions [1-5]. Attention to the process of WD/WHLS has grown in the last decade, as shown by recent surveys [6-14], consensus statements [15-20], and clinical studies [1-5,21]. This literature emphasizes the importance of conducting the process of WD/WHLS with the same degree of empathy and efficiency as other ICU patient care processes [22,23]. While ICUs of teaching hospitals are generally larger and care for a greater proportion of high acuity patients, community hospitals, in aggregate, often account for at least as many ICU beds within a given region [24]. Physicians caring for patients in community hospitals may encounter critically ill patients, and the need to consider WD/WHLS, less frequently than their academic colleagues. Despite the publication of consensus statements, the fact remains that the impact of clinical practice guidelines on practice has been found, in some instances, to be disappointing [25,26]. Academic critical care physicians develop their approach to the process of WD/WHLS by utilizing the literature, personal experience, discussion with their peers, and considering input from multiple health disciplines (nursing, social work, pastoral care). Community physicians may lack the same degree of experience and support. Following the assumption that a difference may exist in physician experience and multidisciplinary support, we hypothesized that the process of WD/WHLS differs between community and academic ICUs. After reviewing the literature, we were unable to find studies describing the process of WD/WHLS in community hospitals. The objectives of this study were to: a) compare the proportion of patients who died as a result of WD/WHLS between a group of community and academic hospital ICUs; and b) describe and compare the process of the withdrawal of life support (WDLS) between these community and teaching hospital ICUs.