Abstract
The purpose of this study was to document the rationale and procedures for withholding and withdrawing life-sustaining treatment in critically ill patients. A prospective observational study was conducted over 12 mo in a Canadian academic intensive care unit. Of the 110 intensive care unit patients who died during the study period, 71 (64.5%) died after treatment was withheld or withdrawn. Compared with the other 39 patients who died despite full therapy, these patients were found to have a longer hospital and ICU stay, more organ systems failed, and a higher rate of malignancy. Intensivists rated poor prognosis for survival and poor quality of life should the patient survive as being the two most important factors when making a decision to withhold or withdraw treatment, while patient age and physical health prior to hospital admission were the two least important factors. There was a consistent approach to withdrawing therapy in 68 of the 71 patients who had treatment either withheld or withdrawn. In these 68 patients, the first step was to write a do-not-resuscitate order, vasopressor drugs were then stopped and, lastly, the patient was weaned from mechanical ventilation and the trachea was extubated. The results of this study demonstrate that life-supporting treatment is commonly withdrawn in critically ill patients when continued therapy is thought to be unlikely to restore the patient to health.
Résumé
Cette étude visait à examiner la logique et la pratique du refus et de l’arrêt du traitement vital chez les malades graves. Cette recherche prospective a été menée au Canada sur une période de 12 mois dans une unité universitaire de soins intensifs. Sur les 100 sujets décédés pendant cette période, 71 décédèrent après un refus ou un arrêt de traitement. Comparativement aux 39 autres patients qui sont morts malgré un traitement exhaustif, on a trouvé que ces patients avaient eu un séjour hospitalier et à l’unité de soins intensifs plus prolongé, que plus de systèmes avaient été défaillants et que la malignité était plus fréquente. Lorsqu’il s’agissait de prendre une décision, les intensivistes ont estimé que le pronostic vital défavorable et que la pauvre qualité de vie anticipée représentaient les deux facteurs les plus importants, alors que l’âge et l’état physique avant l’admission à l’hôpital étaient les deux facteurs les moins importants. En face de la décision de cesser ou de s’abstenir de traiter, l’attitude était cohérente pour 68 des 71 patients. Pour ces 68 patients, le premier pas a été l’émission d’une ordonnance de ne pas réanimer, l’arrêt des vasopresseurs, et finalement, le sevrage du ventilateur et l’extubation de la trachée. Les résultats de cette étude démontrent que les thérapies de soutien vitales sont souvent supprimées chez les malades graves quand on croit que la continuation du traitement n’a pas de chance de ramener la santé.
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The work was carried out in the Intensive Care Unit, Kingston General Hospital, Kingston, Ontario.
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Wood, G.G., Martin, E. Withholding and withdrawing life-sustaining therapy in a Canadian intensive care unit. Can J Anaesth 42, 186–191 (1995). https://doi.org/10.1007/BF03010673
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DOI: https://doi.org/10.1007/BF03010673