Correspondence

Withdrawal of Mechanical Ventilation

N Engl J Med 2003; 349:2565-2567December 25, 2003

Article

To the Editor:

In their report on the withdrawal of mechanical ventilation in anticipation of a patient's death, Cook et al. (Sept. 18 issue)1 state that their findings “suggest that the process of withdrawal of life support is attentive to patients' wishes.” Strictly speaking, the study showed that the process is attentive to caregivers' perceptions of their patients' wishes. How were these perceptions formed?

Social scientists have long argued that end-of-life decision making and practices are shaped by caregivers' implicit moral understanding of what constitutes appropriate care.2 At least two studies show that many experts in the provision of life-support technology would not want the full armamentarium of such measures instituted for themselves.3,4

Is it possible that in the study by Cook et al., the physicians' perceptions that patients preferred not to use life support reflected — at least in part — their own answers to the question, “Would I want this for myself or someone I care about?” The answers to such questions are rooted in personal ontology that we as a medical community must try to understand in order to engage in end-of-life decision making more honestly with our patients and their families.

Michael Nurok, M.B., Ch.B.
Brigham and Women's Hospital, Boston, MA 02115
mnurok@partners.org

4 References

1. 1

   Cook D, Rocker G, Marshall J, et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 2003;349:1123-1132
   Full Text | Web of Science | Medline

2. 2

   Glaser BG, Strauss AL. Awareness of dying. Chicago: Aldine, 1965.
   

3. 3

   Hauswald M, Tanberg D. Out-of-hospital resuscitation preferences of emergency health care workers. Am J Emerg Med 1993;11:221-224
   CrossRef | Web of Science | Medline

4. 4

   Iserson KV, Stocking C. Standards and limits: emergency physicians' attitude toward prehospital resuscitation. Am J Emerg Med 1993;11:592-594
   CrossRef | Web of Science | Medline

To the Editor:

In the study by Cook et al., 6 of the 166 patients who had mechanical ventilation withdrawn because death was thought to be imminent were ultimately discharged from the hospital. It would be very interesting to have a little more information about these patients — in particular, their clinical state at discharge and the interval between the withdrawal decision and discharge.

Georges Offenstadt, M.D.
Bertrand Guidet, M.D.
Hôpital Saint Antoine, 75012 Paris, France
georges.offenstadt@sat.ap-hop-paris.fr

To the Editor:

Cook et al. highlight serious concerns about the everyday practice of critical care. They found that many determinants of the withdrawal of mechanical ventilation were unrelated to the course in the intensive care unit (ICU). Several of the strongest determinants could have been established for some patients before enrollment in a “trial of therapy,” since the quality of life before admission to the ICU influences the outcome.1

It is hard to imagine the physical, psychological, and emotional burdens endured by patients at the end of life and by their families during therapy. Preferences with regard to life-sustaining therapy should be explicitly explored for patients who have chronic or incurable disease with frequent hospitalization, a declining quality of life, and increasing disability, before the onset of critical illness. The practice of critical care should be refocused to examine the wisdom of using life-sustaining therapy and the potential consequences for patients, their families, and society.2 Is the use of instrumentation and machines when death is looming an acceptable form of compassionate care? Life-sustaining therapy is a double-edged sword: it may prolong life, but it will also prolong suffering before death.

Mohamed Y. Rady, M.D., Ph.D.
Mayo Clinic Hospital, Phoenix, AZ 85054

2 References

1. 1

   Rivera-Fernandez RMD, Sanchez-Cruz JJ, Abizanda-Campos R, Vazquez-Mata G. Quality of life before intensive care unit admission and its influence on resource utilization and mortality rate. Crit Care Med 2001;29:1701-1709
   CrossRef | Web of Science | Medline

2. 2

   Angus DC, Carlet J, Brussels P. Surviving intensive care: a report from the 2002 Brussels Roundtable. Intensive Care Med 2003;29:368-377
   Web of Science | Medline

To the Editor:

Your Perspective article, “Decisions at the End of Life” (Sept. 18 issue),1 would be better titled “Decisions at the End of the End of Life.” Unfortunately, many critical decisions are delayed until the last moment of life rather than much earlier, when end-of-life care should be addressed. You are correct in stating that the physician can create a self-fulfilling prophecy, and your personal admonition to physicians regarding advice to families is a sensitive reflection of our ability to influence the outcome. You aptly quote Francis Peabody's statement that “the secret of the care of the patient is caring for the patient.” Such caring needs to start much earlier, and outside of centers for curing, where you work. Decisions should be made when the transition from curing to caring begins. This is in the hands of all practicing physicians who have the opportunity of awakening to the need to recognize the beginning of the end of life. At this point, one can institute palliative strategies in a proactive mode.

Michael Appleton, M.D.
Odyssey HealthCare, Palm Desert, CA 92260

1 References

1. 1

   Drazen JM. Decisions at the end of life. N Engl J Med 2003;349:1109-1110
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Nurok rightly points out that our study suggests that withdrawal of life support is a process attentive to clinicians' perceptions of patients' wishes. This should be the norm in the ICU, where direct, real-time, situation-specific elicitation of patients' values is rare, and where ongoing dialogue between family members and the ICU team is the primary vehicle by which patients' preferences are understood. We concur that ICU clinicians may sometimes inadvertently conflate their own values with those of the patients they care for, thereby modulating life-support decisions, including when, where, and how such decisions are put into operation. We also hypothesize that clinicians' discomfort with death may cause iatrogenic suffering and could influence their perceptions of patients' preferences.1

Drs. Offenstadt and Guidet inquire about the status of the six patients who underwent withdrawal of mechanical ventilation in anticipation of death but who were discharged from the hospital. These patients died after transfer to rehabilitation, palliative care, or long-term care facilities; one patient was taken home and died within 48 hours. For patients whose death was anticipated after the withdrawal of the ventilator, functional status after discharge was not included in our original submission to the Research Ethics Board.

In response to Dr. Rady's comments about suffering: we agree that there is a need for better integration of palliative and critical care.2 Honest, compassionate, and culturally sensitive discussions in which life-support preferences are elicited and honored remain a major objective for multidisciplinary clinicians caring for the most vulnerable patients in the ICU. In our study, we did not find that patients' prior functional status was significantly associated with the withdrawal of mechanical ventilation. Although we anticipated that age and the severity of the illness and organ dysfunction would be key determinants of ventilator withdrawal, multivariate analysis showed that the four strongest determinants were dependency on inotropes or vasopressors, the physician's perception of the patient's preference to limit life support, and the physician's predictions of a low likelihood of survival in the ICU and a high likelihood of poor cognitive function in the future.

Deborah Cook, M.D.
McMaster University, Hamilton, ON L8N 325, Canada

Graeme Rocker, M.D.
Dalhousie University, Halifax, NS B3H 3A7, Canada

Peter Dodek, M.D.
University of British Columbia, Vancouver, BC V6Z 1Y6, Canada

for the Level of Care Study Investigators and the Canadian Critical Care Trials Group

2 References

1. 1

   Kuhl D. What dying people want: practical wisdom for the end of life. Toronto: Doubleday Canada, 2002.
   

2. 2

   Danis M, Federman D, Fins JJ, et al. Incorporating palliative care into critical care education: principles, challenges, and opportunities. Crit Care Med 1999;27:2005-2013
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Appleton points out that one of the duties of a physician is to understand what the patient wants and to tailor the patient's treatment (or lack thereof) accordingly. This process is the basis of a successful therapeutic relationship. It may take years of caring for a patient before a physician can truly understand that person's desires. Unfortunately, in many therapeutic settings, there is no physician who has established such a relationship with the patient. Under these circumstances, we should provide guidance for the patient and family without trying to control the outcome. This is often not easy to do.

Jeffrey M. Drazen, M.D.