Prolonging the Withdrawal of Life Support
in the ICU Affects Family Satisfaction with Care
Clinicians in the intensive care unit (ICU) often care for patients
who are on several life support measures at once. When such a patient
is dying and the decision is reached to withdraw life support,
these clinicians may make an imperfect compromise in seeking to
balance the complex needs of the patient and the patientís family — they
may remove the life support measures one at a time over a period
of days, rather than withdrawing all at once.
According to a paper published in the Oct. 15, 2008, issue of
the American Journal of Respiratory and Critical Care Medicine,
this practice, referred to as sequential withdrawal, may be relatively
common, and may have a varying impact on the familyís satisfaction
with ICU care. This study was funded by the National Institute
of Nursing Research (NINR), the lead Institute for end-of-life
research at the National Institutes of Health (NIH).
"We found that sequential withdrawal of life support is not
as rare a phenomenon as previously thought," said J. Randall
Curtis, M.D., MPH, the principal investigator of the study. "It
occurred in nearly half of the patients we studied."
"The decision to remove a loved one from life supporting
treatment is typically very traumatic for families," said
NINR Director Patricia A. Grady, Ph.D., RN, FAAN. "Once a
patient enters the ICU, clinicians may need to help family members
develop realistic expectations based on the patientís prognosis.
This study highlights the importance of open communication between
clinicians and the family."
The data for this study came from a larger project involving ICUs
in 15 hospitals across the Seattle and Tacoma area in Washington
state. Dr. Curtis and colleagues examined the life support withdrawal
process for 584 patients who died in the ICU or within 24 hours
of discharge from the ICU, and surveyed the family members on their
perceptions of the care provided.
The patients ranged in age from 19 to 99 years, with an average
age of 72 years, 91 percent were white, and 61 percent were male.
A medical chart review found that the patients received a median
number of four life support therapies or interventions within their
last five days of life: 99 percent had laboratory tests done, 83
percent were on mechanical ventilation, 76 percent received intravenous
fluids, 52 percent were on vasopressor medications to sustain blood
pressure, 33 percent received tube feedings, and 9 percent received
When the decision was reached to remove life support, all measures
were withdrawn on the same day for 54 percent of the patients.
For the remaining 46 percent, the process of withdrawal took at
least two days. Among these patients, dialysis was most often the
first therapy withdrawn, and mechanical ventilation the last. Older
patients, those with cancer, neurologic, or respiratory disease,
and those experiencing pain tended to have a shorter duration of
the withdrawal process, while trauma patients had the longest.
The presence of a living will did not influence the duration of
the withdrawal process.
Among the families, 95 percent participated in a family conference
with the ICU clinicians during the last week of the patientís life.
Having more family members involved in making decisions tended
to prolong the withdrawal process. When surveyed one to two months
after the death, family members of patients who had a short ICU
stay reported a lower satisfaction with the ICU care if the withdrawal
process was extended over more than one day. However, for family
members of patients who had a long ICU stay (eight days or more),
satisfaction with care increased with a more extended duration
of the withdrawal. In addition, family satisfaction with care was
higher if the patient was off the ventilator at the time of death.
Of particular interest was the finding that the families of patients
who had experienced a longer ICU stay tended to prefer the more
extended, sequential withdrawal process. "This finding is
in the opposite direction of our original hypothesis," stated
Dr. Curtis. "We believed that extending the withdrawal process
would lower the satisfaction with care among all families. A longer
duration of withdrawal of life support seems unlikely to benefit
the patient, because it prolongs non-beneficial and sometimes painful
"After making the decision to withdraw life support measures
from a dying patient in the ICU, some physicians may slow down
the withdrawal process to give the family more time to cope," noted
Dr. Grady. "The outcome of this study indicates that nurses
and physicians need to continue to work with the family throughout
the patientís ICU stay to provide them with accurate information
on which to base decisions, and prepare them emotionally for the
possible loss of their loved one."
NINR supports basic and clinical research that develops the knowledge
to build the scientific foundation for clinical practice, prevent
disease and disability, manage and eliminate symptoms caused by
illness, and enhance end-of-life and palliative care. For more
information about NINR, visit the website at www.ninr.nih.gov.
The National Institutes of Health (NIH) — The Nation's
Medical Research Agency — includes 27 Institutes and
Centers and is a component of the U.S. Department of Health and
Human Services. It is the primary federal agency for conducting
and supporting basic, clinical and translational medical research,
and it investigates the causes, treatments, and cures for both
common and rare diseases. For more information about NIH and
its programs, visit www.nih.gov.
Gerstel E, Engelberg RA, Koepsell T, Curtis JR. Duration of withdrawal
of life support in the intensive care unit and association with family
satisfaction. American Journal of Respiratory and Critical Care
Medicine. 2008; 178: 798-804.