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ABSTRACT |
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INTRODUCTION
METHODS
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DISCUSSION
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In some intensive care units (ICUs), fewer patients who die now undergo attempts at cardiopulmonary resuscitation (CPR), and many more have life support actively withdrawn prior to death than did a decade ago. To determine the frequency of withdrawal of life support, we contacted every American postgraduate training program with significant clinical exposure to critical care medicine, asking them prospectively to classify patients who died into one of five mutually exclusive categories. We received data from 131 ICUs at 110 institutions in 38 states. There were 6,303 deaths, of which 393 patients were brain dead. Of the remaining 5,910 patients who died, 1,544 (23%) received full ICU care including failed cardiopulmonary resuscitation (CPR); 1,430 (22%) received full ICU care without CPR; 797 (10%) had life support withheld; and 2,139 (38%) had life support withdrawn. There was wide variation in practice among ICUs, with ranges of 4 to 79%, 0 to 83%, 0 to 67%, and 0 to 79% in these four categories, respectively. Variation was not related to ICU type, hospital type, number of admissions, or ICU mortality. We conclude that limitation of life support prior to death is the predominant practice in American ICUs associated with critical care training programs. There is wide variation in end-of-life care, and efforts are needed to understand practice patterns and to establish standards of care for patients dying in ICUs.
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INTRODUCTION |
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ABSTRACT
INTRODUCTION
METHODS
RESULTS
DISCUSSION
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There is a widespread perception that intensive medical care at the end of life frequently represents excessive, inappropriate use of technology. The report of the most extensive investigation of death in American hospitals, the 4-yr, multicenter Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), begins with the assertion that "physicians . . . provide more extensive treatment to seriously ill patients than they would choose for themselves," and concludes that too much of the dying patient's time is spent in the "undesirable" states of being comatose, in an intensive care unit (ICU), or receiving mechanical ventilation (1). There are abundant anecdotal reports (2) as well as recent survey data (3) to support the view that medical care at the end of life is driven by technology and is insensitive to patient preferences. A recent review of the management of withdrawal of life support also starts from this premise (4).
We recently reported data that challenge this perception. In two hospitals affiliated with the University of California, San Francisco (UCSF), we documented a significant increase over 5 yr in the frequency of withholding and withdrawal of life support from patients dying in ICUs (5). In 1987-1988, 51% of patients who died in an ICU had some form of life support withheld or withdrawn; in 1992-1993 this percentage rose to 90% (5). These findings and those in other studies (6, 7) show that some critical care physicians limit life-sustaining interventions for their patients in an attempt to avoid inappropriate care. However, it remains unknown to what extent practice at UCSF is similar to that at other institutions in other parts of the United States. We conducted the current study to assess the generalizability of our earlier findings at UCSF by characterizing patterns of ICU deaths nationally. In particular, we sought to determine the frequency of use of cardiopulmonary resuscitation (CPR) and the extent of variability in the active withdrawal of life support.
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METHODS |
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ABSTRACT
INTRODUCTION
METHODS
RESULTS
DISCUSSION
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We used listings published by the American Thoracic Society and the Society of Critical Care Medicine to identify every American postgraduate training program with significant clinical exposure to critical care medicine. We contacted each program director by mail and phone to invite him or her to participate in a prospective, observational study. In a handful of cases, these contacts recommended other local physicians interested in end-of-life care, and we invited their institutions to participate. A list of participating institutions and their ICU directors is given in the APPENDIX.
We provided participating directors with a single-page data-collection form (available on request), asking them prospectively to categorize all patients who died in their ICUs into one of five mutually exclusive categories: patients receiving aggressive management, including failed cardiopulmonary resuscitation (CPR group); those receiving aggressive management up to but not including CPR (do not resuscitate, or DNR group); those with an identified antemortem decision to withhold some form of life support (withholding group); those with an identified antemortem decision to withdraw an existing form of life support (withdrawal group); and patients formally declared braindead. We provided participating centers with standardized definitions of each of these categories, summarized in Table 1. We did not ask institutions to follow and report the outcomes of patients transferred out of the ICU after a decision to withhold or withdraw therapy.
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A determination of brain death generally leads to withdrawal of mechanical ventilation. In this situation, the family may link a patient's death to removal of the ventilator rather than to cessation of brain function, and issues surrounding withdrawal of ventilation may arise despite the medical determination of death (8). We chose in this study to exclude brain-dead patients from analyses of end-of-life decisions because the law on this matter is unequivocal: The patient is dead once a determination of brain death has been made. Subsequent decisions are therefore sufficiently different from matters of resuscitation and from the withdrawal of life support from living patients to make their inclusion confuse the analysis.
The Committee on Human Research at UCSF reviewed the proposal for the study and approved the study design, noting that there would be no contact with patients and no information collected that could identify any individual patient. Several participating institutions raised a separate concern that individual hospitals not be identified in presentation of the data. We agreed to report aggregate data only.
Institutions began enrolling patients for six consecutive months on the first of the month at any time between November 1, 1994 and April 1, 1995. The last data were collected in October 1995.
Data were entered into a Macintosh personal computer (Apple, Inc., Cupertino, CA) using FileMaker Pro and Microsoft Excel (Microsoft, Seattle, WA) for data manipulation and Stata (Claris Corp., Santa Clara, CA) for statistical analyses. Tests of differences between ICUs were done with median values, using the Kruskal-Wallis test. Bonferroni's correction was used in the setting of multiple comparisons. Multiple logistic regression was used to determine whether number of admissions or ICU mortality predicted a high proportion of deaths in any single category.
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RESULTS |
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One hundred sixty-seven (73%) of 229 sites agreed to participate. We received data from 110 institutions (66% response rate, 48% overall participation) representing 131 separate ICUs in 38 states. Two institutions reported 5 mo of data and a third reported 4 mo; these data were included in the analyses. Two other institutions reported withholding and withdrawal of life support as a combined category; these data were excluded from the analyses.
Aggregate results are presented in Table 2. Of 5,910 patients facing end-of-life decisions, 74% received less than full ICU support. Results organized by ICU are shown in Table 3. Across the 131 ICUs for which data were analyzed, median proportions of ICU deaths after failed CPR, DNR status, withholding of life support, and withdrawal of life support were 23%, 22%, 10%, and 38%, respectively. ICUs varied in their number of admissions according to ICU type and hospital type. There was significant variation in mortality among different types of ICU. Despite this variation, neither the number of admissions nor ICU mortality was predictive in multiple logistic regression analysis of an ICU being in the upper quartile of any category of death (range of odds ratios [OR] with 95% confidence intervals [CI]: 0.84 [range: 0.57 to 1.24] to 1.19 [range: 0.80 to 1.78]).
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The most striking finding was the wide variation in all categories of death. Figure 1 shows that the ranges of proportions of death preceded by failed CPR, DNR status, withholding of life support, and withdrawal of life support were 4 to 79%, 0 to 83%, 0 to 67%, and 0 to 79%, respectively. This variation did not change when controlling for the number of deaths by eliminating ICUs with less than the median number of deaths (42), as depicted for withdrawal of life support in Figure 2.
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There was a trend toward regional differences in all categories of end-of-life care, particularly with CPR rates. This did not reach statistical significance when correction was made for multiple comparisons. However, there was a pattern observed in the two regions that included states with strict legal standards for withdrawal of life support by surrogate decision makers. ICUs in New York and Missouri had lower proportions of deaths preceded by withdrawal of life support than did the Middle Atlantic and Midwest regions, respectively. This was statistically significant in New York, but not in Missouri, owing to the small number of participating sites in that state. Included in Figure 2 is a demarcation (open circles) of the ICUs in New York and Missouri.
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DISCUSSION |
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ABSTRACT
INTRODUCTION
METHODS
RESULTS
DISCUSSION
REFERENCES
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In this broad, prospective survey of deaths in American ICUs, we found a high frequency of decisions to limit life-sustaining therapy. The median practice in 131 ICUs was to limit life support in 70% of deaths, with a median of 48% of deaths following the withholding or active withdrawal of life support. Nationwide, the median practice was to attempt CPR in only 23% of ICU patients who died.
At first glance, these findings suggest that setting limits to life support has become so commonplace as to represent a de facto standard of end-of-life care for critically ill patients. However, the extreme variation in each of the four categories of ICU practice examined in our study underscores the absence of any consensual approach to end-of-life care. The observed variation in practice was not explained by hospital type, ICU type, mortality, or number of admissions. The absence of any predictor of this variation suggests three conclusions. First, the explanation for the observed variation may lie in the beliefs and local practice patterns of groups of physicians, particularly the ICU attending staff at a given hospital. Given the changes in the medical approach to terminally ill patients since the Quinlan decision (9), this is not surprising: For more than two decades, Wennberg and colleagues have documented widespread variations in many areas of medical practice, some of which are best explained by differences in professional opinion (10).
Second, the variability in end-of-life care of critically ill patients documented nationwide in 1994-1995 may reflect the same evolution in practice documented in San Francisco from 1988 to 1993, but occurring at different rates and currently at different stages in different parts of the country. This inference is limited by the absence of cross-sectional data on withdrawal of life support from the 1980s, or of longitudinal data from any other institutions on frequency of withdrawal of life support. It remains unproved whether there was more or less variation in practice than a decade ago.
Third, there are no recognized standards of practice in this important area of medical care.
Our study has limitations. First, we did not capture all end-of-life decisions in the ICU. To simplify data collection, we did not require institutions to follow and to report the outcome of patients transferred out of the ICU after a decision to withhold or withdraw therapy. In the 1992-1993 UCSF withdrawal study (5), 13 patients of 179 who had recommendations to limit life support (7%) were transferred out of the ICU; all subsequently died. Therefore, we suspect that the design of the present study slightly underestimates the frequency of withholding and withdrawal of life support. Second, our categories were designed to be mutually exclusive, but assignment to a category was at the discretion of the participating institutions. It is possible that assignment was not uniform across all sites. However, classification questions arose infrequently: One of us (T.P.) handled telephone calls from participating institutions with questions, and received less than a dozen over the course of the study. Third, almost all ICUs were associated with postgraduate training programs in critical care medicine. The management of dying patients in ICUs not associated with teaching hospitals might be different, although we did not observe such a difference in the small number of community hospitals included in this study. Additionally, the overall participation rate in the study was only 48%. We note that a higher response rate would be likely to increase rather than to reduce the variation in practice we observed.
The differences in end-of-life care between Missouri and the midwest, and between New York State and the middle Atlantic states, suggest that judicial rulings have an impact on medical practice. The cases of Mary O'Connor in New York (11) and Nancy Cruzan (12) in Missouri have contributed to anomalous standards for surrogate decision-making in those states. If a patient lacks decision-making capacity in New York, he or she may have life support withdrawn only if there is a legally designated health-care proxy or an advance directive that explicitly states that the patient wanted the particular intervention in question discontinued. Anything less specific requires continued treatment. Since most patients facing end-of-life decisions in ICUs lack decision-making capacity (only 3 to 4% were able to participate in their end-of-life care in two recent studies [5, 13]), such standards skew medical practice toward excessive use of technology.
The wide variation observed in this study points to the lack of consensual guidelines for end-of-life care. In the 131 ICUs for which we analyzed data, the median frequency of CPR among patients who died was 23%, but the range of practice is provocative. In some ICUs, more than 75% of deaths followed failed CPR; two other ICUs reported CPR prior to only 4% of deaths. The frequency of withdrawal of life support also varied widely. Thirteen ICUs had withdrawal frequencies of less than 5%, with the six lowest combining to represent 2,740 admissions and 226 deaths, but not a single case of withdrawal of life support.
Extreme variation in practice therefore occurs for both aggressive and nonaggressive end-of-life care. Much analysis of end-of-life care is critical of the excessive use of technology, but with CPR rates of 4%, too little care may sometimes be provided. In an era when physicians may have financial incentives for limiting life support, there is an increased need for explicit public guidelines for end-of-life practice. The reality is that we do not know the appropriate frequency of failed CPR or the minimum acceptable frequency of withdrawal of life support. This lack of benchmarks for end-of-life care is understandable given both the novelty and volatility of the issues. However, the absence of accepted guidelines may contribute to the perception that end-of-life care is haphazard and insensitive to patient preference.
A first step in creating consensus is to insist that institutions track their own end-of-life practices. Hospitals currently monitor all resuscitation attempts, using published algorithms as a practice reference and maintaining longitudinal statistics to identify potential problems. The same effort needs to be made to track other approaches to end-of-life care, especially now that only a minority of dying patients receive attempts at resuscitation. At the same time, there is a clear need for a national forum in which such internal statistics may be shared with other institutions. If physician beliefs and local practice patterns cause outliers in end-of-life care, the solution begins by shedding light on practices that have been kept hidden for too long, to the detriment of patients and physicians alike.
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Footnotes |
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Correspondence and requests for reprints should be addressed to Thomas J. Prendergast, M.D., Chief, Pulmonary Section (111), VA Medical Center, White River Junction, VT 05009-0001. E-mail: thomas.j.prendergast{at}hitchcock.org
(Received in original form January 27, 1998 and in revised form May 20, 1998).
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References |
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INTRODUCTION
METHODS
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DISCUSSION
REFERENCES
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1.
The SUPPORT Principal Investigators.
1995.
A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).
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Hansot, E..
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A letter from a patient's daughter.
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3. Danis, M., E. Mutran, J. M. Garrett, S. C. Stearns, R. T. Slifkin, L. Hanson, J. F. Williams, and L. R. Churchill. 1996. A prospective study of the impact of patient preferences on life-sustaining treatment and hospital cost. Crit. Care Med 24: 1811-1817 [Medline].
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Brody, H.,
M. L. Campbell,
K. Faber-Langendoen, and
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5. Prendergast, T. J., and J. M. Luce. 1997. Increasing incidence of withholding and withdrawal of life support from the critically ill. Am. J. Respir. Crit. Care Med. 155: 15-20 [Abstract].
6. Faber-Langendoen, K., and D. M. Bartels. 1992. Process of forgoing life-sustaining treatment in a university hospital: an empirical study. Crit. Care Med 20: 570-577 [Medline].
7. Koch, K. A., H. D. Rodeffer, and R. L. Wears. 1994. Changing patterns of terminal care management in an intensive care unit. Crit. Care Med 22: 233-243 [Medline].
8. New York Times. 1994. Brain-dead Florida girl will be sent home on life support. February 19, 1994. 11.
9. Prendergast, T. J.. 1997. Resolving conflicts surrounding end-of-life care. New Horiz. 5: 62-71 [Medline].
10. Center for the Evaluative Clinical Sciences, Dartmouth Medical School. 1998. The Dartmouth Atlas of Health Care 1998. American Hospital Publishing, Chicago, IL.
11. Gindes, D.. 1989. Judicial postponement of death recognition: the tragic case of Mary O'Connor. Am. J. Law Med. 15: 301-331 [Medline].
12. Cruzan v. Director, Missouri Department of Health. 1990. 497 U.S. 261 (1990).
13. Smedira, N. G., B. H. Evans, L. S. Grais, N. H. Cohen, B. Lo, M. Cooke, W. P. Schecter, C. Fink, E. Epstein-Jaffe, C. May, and J. M. Luce. 1990. Withholding and withdrawal of life support from the critically ill. N. Engl. J. Med 322: 309-315 [Abstract].
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APPENDIX |
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Participating Physicians and Institutions
Michael E. Westley, M.D., Alaska Native Medical Center, Anchorage, AK; John I. Kennedy Jr., M.D., University of Alabama Medical Center, Birmingham, AL; Michael P. Houston, M.D., USA-Knollwood Hospital, Mobile, AL; Paula J. Anderson, M.D., University of Arkansas for Medical Sciences, Little Rock, AR; John E. Heffner, M.D., St. Joseph's Hospital and Medical Center, Phoenix, AZ; Stuart F. Quan, M.D., University of Arizona Health Sciences Center, Tucson, AZ; Darryl Y. Sue, M.D., Harbor-University of California at Los Angeles Medical Center, Torrance, CA; Paul A. Selecky, M.D., Hoag Memorial Hospital, Newport Beach, CA; Lewis S. Lehman, M.D., Kaiser Permanente Hospital, San Francisco, CA; Michael S. Bernstein, M.D., Kaiser Permanente Medical Center, Oakland, CA; David H. Wong, Pharm. D., M.D., Long Beach Veterans Administration Medical Center, Long Beach, CA; Thomas E. Addison, M.D., Mount Zion Hospital, San Francisco, CA; John M. Luce, M.D., San Francisco General Hospital, San Francisco, CA; Timothy E. Albertson, M.D., and David H. Wisner, M.D., University of California Davis Medical Center, Sacramento, CA; Matthew Brenner, M.D., University of California Irvine Medical Center, Orange, CA; William B. Auger, M.D., University of California San Diego Medical Center, San Diego, CA; Neal H. Cohen, M.D., and Thomas J. Prendergast, M.D., University of California San Francisco, San Francisco, CA; David Gelmont, M.D., University of Southern California, Los Angeles, CA; Carolyn H. Welsh, M.D., Veterans Affairs Medical Center, Denver, CO; Neil S. Yeston, M.D., Hartford Hospital-University of Connecticut, Hartford, CT; Lewis Berman, M.D., Norwalk Hospital, Norwalk, CT; Daniel P. McNally, M.D., University of Connecticut Health Center, Farmington, CT; Mark D. Siegel, M.D., Yale-New Haven Medical Center, New Haven, CT; Michael G. Seneff, M.D., George Washington University Medical Center, Washington, DC; Arthur C. St. Andre, M.D., Washington Hospital Center, Washington, DC; T. James Gallagher, M.D., University of Florida College of Medicine-Shands Hospital, Gainesville, FL; Joseph M. Civetta, M.D., University of Miami School of Medicine, Miami, FL; Roy D. Cane, M.B., B.Ch., University of South Florida, Tampa, FL; Gerald W. Staton Jr., M.D., Crawford Long Hospital, Atlanta, GA; Diane Johnson, M.D., Kaiser Permanente Hospital, Honolulu HI; Charles G. Alex, M.D., Hines Veterans Administration Medical Center, Hines, IL; Joan D. Boomsma, M.D., Northwestern Memorial Hospital, Chicago, IL; Jeffrey S. Soble, M.D., Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL; Lawrence D. Wood, M.D., Ph.D., University of Chicago, Chicago, IL; Susan K. Pingleton, M.D., University of Kansas Medical Center, Kansas City, KS; Alexander Tzouanakis, M.D., University of Kentucky Medical Center, Lexington, KY; Ben de Boisblanc, M.D., Medical Center of Louisiana (Charity Hospital), New Orleans, LA; Geoffrey R. Sheinfeld, M.D., Bay State Medical Center, Springfield, MA; Alan Lisbon, M.D., and Steven E. Weinberger, M.D., Beth Israel Hospital, Boston, MA; Richard C. Dennis, M.D., Boston University School of Medicine, Boston, MA; L. Jack Faling, M.D., Boston Veterans Affairs Medical Center, Boston, MA; Leonard D. Sicilian, M.D., New England Medical Center, Boston, MA; Alexandra Flather-Morgan, M.D., and B. Taylor Thompson, M.D., Massachusetts General Hospital, Boston, MA; Stephen Heard, M.D., University of Massachusetts Medical Center, Worcester, MA; James H. Shelhamer, M.D., National Institutes of Health, Bethesda, MD; Paul M. Cox Jr., M.D., Maine Medical Center, Portland, ME; Marilyn T. Haupt, M.D., Detroit Receiving Hospital, Detroit, MI; H. Matilda Horst, M.D., and John Popovich Jr., M.D., Henry Ford Hospital, Detroit, MI; Steve G. Peters, M.D., Mayo Clinic Medical Center, Rochester, MN; Frank B. Cerra, M.D., University of Minnesota Hospitals, Minneapolis, MN; Christopher Veremakis, M.D., St. John's Mercy Medical Center, Saint Louis, MO; George M. Matuschak, M.D., St Louis University Medical Center, St Louis, MO; Gary A. Salzman, M.D., University of Missouri-Kansas City, Kansas City, MO; Marcy F. Petrini, Ph.D., University of Mississippi Medical Center, Jackson, MS; Samia Fakhry, M.D., University of North Carolina Hospitals and Clinics, Chapel Hill, NC; Walter J. O'Donohue Jr., M.D., Creighton University School of Medicine, Omaha, NE; Harold L. Manning, M.D., Dartmouth-Hitchcock Medical Center, Lebanon, NH; W. Eric Scott, M.D., University of Medicine and Dentistry of New Jersey- Cooper Hospital, Camden, NJ; Matthew G. Marin Jr., M.D., University Hospital, Newark, NJ; Howard Levy, M.D., University of New Mexico, Albuquerque, NM; Sophia Socaris, M.D., Albany Medical College, Albany, NY; Mark J. Rosen, M.D., Beth Israel Medical Center, New York City, NY; Carlos R. Ortiz, M.D., Genesee Hospital, Rochester, NY; Yizhak Kupfer, M.D., Maimonides Medical Center, Brooklyn, NY; Vladimir Kvetan, M.D., Montefiore Medical Center, Bronx, NY; John M. Oropello, M.D., Mount Sinai Medical Center, New York, NY; George P. Maguire, M.D., New York Medical College, Valhalla, NY; Martin E. Doerfler, M.D., New York University Medical Center, New York, NY; David Lee, M.D., Rochester General Hospital, Rochester, NY; Ira Wagner, M.D., St. Vincent's Hospital and Medical Center, New York, NY; Alan T. Aquilina, M.D., State University of New York at Buffalo, Buffalo, NY; Timothy E. Page, M.D., State University of New York Health Sciences Center, Syracuse, Syracuse, NY; Michael Apostokalos, M.D., and Niels Lund, M.D., Ph.D., University of Rochester Medical Center, Rochester, NY; Michael S. Niederman, M.D., Winthrop University Hospital, Mineola, NY; Herbert P. Wiedemann, M.D., Cleveland Clinic Foundation, Cleveland, OH; Louis Flancbaum, M.D., and Eric R. Pacht, M.D., Ohio State University Hospital, Columbus, OH; Mitchell C. Rashkin, M.D., University of Cincinnati Medical Center, Cincinnati, OH; James Rowbottom, M.D., University Hospitals of Cleveland, Cleveland, OH; Paul V. Carlile, M.D., University of Oklahoma Health Sciences Center and Veterans Affairs Medical Center, Oklahoma City, OK; Robert B. Dreisin, M.D., Providence Medical Center, Portland, OR; Jan Liebler, M.D., Oregon Health Sciences University, Portland, OR; Molly L. Osborne, M.D., Ph.D., Veterans Administration Medical Center, Portland, OR; Michael L. Lippmann, M.D., Albert Einstein Medical Center, Philadelphia, PA; Donald G. Raible, M.D., Hahnemann University Hospital, Philadelphia, PA; Paul N. Lanken, M.D., and Clifford S. Deutschman, M.D., Hospital of the University of Pennsylvania, Philadelphia, PA; Arthur H. Combs, M.D., Medical College of Pennsylvania, Philadelphia, PA; Michael R. Pinsky, M.D., Oakland Veterans Administration Medical Center, Montefiore Hospital, and Presbyterian University Hospital, Pittsburgh, PA; John L. Stauffer, M.D., The Milton S. Hershey Medical Center, Hershey, PA; Gregory C. Kane, M.D., Thomas Jefferson University Hospital, Philadelphia, PA; Steven A. Sahn, M.D., Medical University of South Carolina, Charleston, SC; Richard G. Wunderink, M.D., University of Tennessee at Memphis and Veterans Administration Medical Center, Memphis, TN; Gordon R. Bernard, M.D., Vanderbilt University, Nashville, TN; Gerald R. Harrington, M.D., Brooke Army Medical Center, Fort Sam Houston, TX; Lynn Keenan, M.D., William Beaumont Army Medical Center, El Paso, TX; Lindell K. Weaver, M.D., Cottonwood Hospital Medical Center and Latter Day Saints Hospital, Salt Lake City, UT; John R. Michael, M.D., University of Utah School of Medicine, Salt Lake City, UT; Kevin R. Cooper, M.D., Medical College of Virginia, Richmond, VA; Charles G. Durbin, M.D., University of Virginia HSC, Charlottesville, VA; Stephen W. Crawford, M.D., Fred Hutchinson Cancer Research Center, Seattle, WA; W. Hal Cragun, M.D., Madigan Army Medical Center, Tacoma, WA; John F. Cramer III, M.D., Providence General Hospital, Everett, WA; Richard J. Maunder, M.D., Swedish Hospital Medical Center, Seattle, WA; Kenneth W. Presberg, M.D., Medical College of Wisconsin, Milwaukee, WI.
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Y.-Y. Chen, A. F. Connors Jr, and A. Garland Effect of Decisions to Withhold Life Support on Prolonged Survival Chest, June 1, 2008; 133(6): 1312 - 1318. [Abstract] [Full Text] [PDF]
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P. N. Lanken, P. B. Terry, H. M. DeLisser, B. F. Fahy, J. Hansen-Flaschen, J. E. Heffner, M. Levy, R. A. Mularski, M. L. Osborne, T. J. Prendergast, et al. An Official American Thoracic Society Clinical Policy Statement: Palliative Care for Patients with Respiratory Diseases and Critical Illnesses Am. J. Respir. Crit. Care Med., April 15, 2008; 177(8): 912 - 927. [Full Text] [PDF]
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 D C Malloy, J Williams, T Hadjistavropoulos, B Krishnan, M Jeyaraj, E F McCarthy, M Murakami, S Paholpak, J Mafukidze, and B Hillis Ethical decision-making about older adults and moral intensity: an international study of physicians J. Med. Ethics, April 1, 2008; 34(4): 285 - 296. [Abstract] [Full Text] [PDF]
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H. Shanawani, M. D. Wenrich, M. R. Tonelli, and J. R. Curtis Meeting Physicians' Responsibilities in Providing End-of-Life Care Chest, March 1, 2008; 133(3): 775 - 786. [Abstract] [Full Text] [PDF]
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J. R. Curtis and R. A. Burt Point: The Ethics of Unilateral "Do Not Resuscitate" Orders: The Role of "Informed Assent" Chest, September 1, 2007; 132(3): 748 - 751. [Full Text] [PDF]
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D. B. White, J. R. Curtis, L. E. Wolf, T. J. Prendergast, D. B. Taichman, G. Kuniyoshi, F. Acerra, B. Lo, and J. M. Luce Life Support for Patients without a Surrogate Decision Maker: Who Decides? Ann Intern Med, July 3, 2007; 147(1): 34 - 40. [Abstract] [Full Text] [PDF]
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 S. Nava, C. Sturani, S. Hartl, G. Magni, M. Ciontu, A. Corrado, A. Simonds, and on behalf of the European Respiratory Society Task End-of-life decision-making in respiratory intermediate care units: a European survey Eur. Respir. J., July 1, 2007; 30(1): 156 - 164. [Abstract] [Full Text] [PDF]
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J. P. Harrison and D. Ford A Comprehensive Community-Based Model for Hospice Care American Journal of Hospice and Palliative Medicine, April 1, 2007; 24(2): 119 - 125. [Abstract] [PDF]
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 D. B. White, C. H. Braddock III, S. Bereknyei, and J. R. Curtis Toward Shared Decision Making at the End of Life in Intensive Care Units: Opportunities for Improvement Arch Intern Med, March 12, 2007; 167(5): 461 - 467. [Abstract] [Full Text] [PDF]
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A. Garland, Z. Shaman, J. Baron, and A. F. Connors Jr. Physician-attributable Differences in Intensive Care Unit Costs: A Single-Center Study Am. J. Respir. Crit. Care Med., December 1, 2006; 174(11): 1206 - 1210. [Abstract] [Full Text] [PDF]
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 E. G. Seferian and B. Afessa Adult Intensive Care Unit Use at the End of Life: A Population-Based Study Mayo Clin. Proc., July 1, 2006; 81(7): 896 - 901. [Abstract] [Full Text] [PDF]
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 D. L.-M. Wiegand Families and Withdrawal of Life-Sustaining Therapy: State of the Science Journal of Family Nursing, May 1, 2006; 12(2): 165 - 184. [Abstract] [PDF]
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 B. J. Daly End-of-Life Decision Making, Organ Donation, and Critical Care Nurses Crit. Care Nurse, April 1, 2006; 26(2): 78 - 86. [Full Text] [PDF]
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D. L.-M. Wiegand Withdrawal of Life-Sustaining Therapy After Sudden, Unexpected Life-Threatening Illness or Injury: Interactions Between Patients' Families, Healthcare Providers, and the Healthcare System Am. J. Crit. Care., March 1, 2006; 15(2): 178 - 187. [Abstract] [Full Text] [PDF]
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A. Yaguchi, R. D. Truog, J. R. Curtis, J. M. Luce, M. M. Levy, C. Melot, and J.-L. Vincent International Differences in End-of-Life Attitudes in the Intensive Care Unit: Results of a Survey Arch Intern Med, September 26, 2005; 165(17): 1970 - 1975. [Abstract] [Full Text] [PDF]
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 R. G. Holloway, C. G. Benesch, W. S. Burgin, and J. B. Zentner Prognosis and Decision Making in Severe Stroke JAMA, August 10, 2005; 294(6): 725 - 733. [Abstract] [Full Text] [PDF]
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R. D. Stapleton, B. M. Wang, L. D. Hudson, G. D. Rubenfeld, E. S. Caldwell, and K. P. Steinberg Causes and Timing of Death in Patients With ARDS Chest, August 1, 2005; 128(2): 525 - 532. [Abstract] [Full Text] [PDF]
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A. Garland Improving the ICU: Part 1 Chest, June 1, 2005; 127(6): 2151 - 2164. [Abstract] [Full Text] [PDF]
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C. R. Levy, E. W. Ely, K. Payne, R. A. Engelberg, D. L. Patrick, and J. R. Curtis Quality of Dying and Death in Two Medical ICUs: Perceptions of Family and Clinicians Chest, May 1, 2005; 127(5): 1775 - 1783. [Abstract] [Full Text] [PDF]
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J. R. Curtis, R. A. Engelberg, M. D. Wenrich, S. E. Shannon, P. D. Treece, and G. D. Rubenfeld Missed Opportunities during Family Conferences about End-of-Life Care in the Intensive Care Unit Am. J. Respir. Crit. Care Med., April 15, 2005; 171(8): 844 - 849. [Abstract] [Full Text] [PDF]
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G. Bosshard, T. Nilstun, J. Bilsen, M. Norup, G. Miccinesi, J. J. M. van Delden, K. Faisst, A. van der Heide, and for the European End-of-Life (EURELD) Consortium Forgoing Treatment at the End of Life in 6 European Countries Arch Intern Med, February 28, 2005; 165(4): 401 - 407. [Abstract] [Full Text] [PDF]
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D. J. Jakobson, L. A. Eidelman, T. M. Worner, A. E. Oppenheim, R. Pizov, and C. L. Sprung Evaluation of Changes in Forgoing Life-Sustaining Treatment in Israeli ICU Patients Chest, December 1, 2004; 126(6): 1969 - 1973. [Abstract] [Full Text] [PDF]
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J. D. Chan, P. D. Treece, R. A. Engelberg, L. Crowley, G. D. Rubenfeld, K. P. Steinberg, and J. R. Curtis Narcotic and Benzodiazepine Use After Withdrawal of Life Support: Association With Time to Death? Chest, July 1, 2004; 126(1): 286 - 293. [Abstract] [Full Text] [PDF]
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 J-L Vincent, J Berre, and J Creteur Withholding and withdrawing life prolonging treatment in the intensive care unit: a current European perspective Chronic Respiratory Disease, April 1, 2004; 1(2): 115 - 120. [Abstract] [PDF]
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M. A. Kelley, D. Angus, D. B. Chalfin, E. D. Crandall, D. Ingbar, W. Johanson, J. Medina, C. N. Sessler, and J. S. Vender The Critical Care Crisis in the United States: A Report From the Profession Chest, April 1, 2004; 125(4): 1514 - 1517. [Full Text] [PDF]
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 D. Cook, G. Rocker, J. Marshall, P. Sjokvist, P. Dodek, L. Griffith, A. Freitag, J. Varon, C. Bradley, M. Levy, et al. Withdrawal of Mechanical Ventilation in Anticipation of Death in the Intensive Care Unit N. Engl. J. Med., September 18, 2003; 349(12): 1123 - 1132. [Abstract] [Full Text] [PDF]
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C. L. Sprung, S. L. Cohen, P. Sjokvist, M. Baras, H.-H. Bulow, S. Hovilehto, D. Ledoux, A. Lippert, P. Maia, D. Phelan, et al. End-of-Life Practices in European Intensive Care Units: The Ethicus Study JAMA, August 13, 2003; 290(6): 790 - 797. [Abstract] [Full Text] [PDF]
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G. M. Rocker and J. R. Curtis Caring for the Dying in the Intensive Care Unit: In Search of Clarity JAMA, August 13, 2003; 290(6): 820 - 822. [Full Text] [PDF]
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D. K. Heyland, G. M. Rocker, C. J. O'Callaghan, P. M. Dodek, and D. J. Cook Dying in the ICU: Perspectives of Family Members Chest, July 1, 2003; 124(1): 392 - 397. [Abstract] [Full Text] [PDF]
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M. L. Campbell and J. A. Guzman Impact of a Proactive Approach to Improve End-of-Life Care in a Medical ICU Chest, January 1, 2003; 123(1): 266 - 271. [Abstract] [Full Text] [PDF]
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 J. Way, A. L Back, and J R. Curtis Withdrawing life support and resolution of conflict with families BMJ, December 7, 2002; 325(7376): 1342 - 1345. [Full Text] [PDF]
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T. J. Prendergast and K. A. Puntillo Withdrawal of Life Support: Intensive Caring at the End of Life JAMA, December 4, 2002; 288(21): 2732 - 2740. [Abstract] [Full Text] [PDF]
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 A Y Goh and Q Mok Identifying futility in a paediatric critical care setting: a prospective observational study Arch. Dis. Child., March 1, 2001; 84(3): 265 - 268. [Abstract] [Full Text]
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K. Faber-Langendoen and P. N. Lanken Dying Patients in the Intensive Care Unit: Forgoing Treatment, Maintaining Care Ann Intern Med, December 5, 2000; 133(11): 886 - 893. [Abstract] [Full Text] [PDF]
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J. M. LUCE and A. ALPERS Legal Aspects of Withholding and Withdrawing Life Support from Critically Ill Patients in the United States and Providing Palliative Care to Them Am. J. Respir. Crit. Care Med., December 1, 2000; 162(6): 2029 - 2032. [Full Text]
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R. I. Hall and G. M. Rocker End-of-Life Care in the ICU : Treatments Provided When Life Support Was or Was Not Withdrawn Chest, November 1, 2000; 118(5): 1424 - 1430. [Abstract] [Full Text] [PDF]
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S. J. Goodlin, Z. Zhong, J. Lynn, J. M. Teno, J. P. Fago, N. Desbiens, A. F. Connors Jr, N. S. Wenger, and R. S. Phillips Factors Associated With Use of Cardiopulmonary Resuscitation in Seriously Ill Hospitalized Adults JAMA, December 22, 1999; 282(24): 2333 - 2339. [Abstract] [Full Text] [PDF]
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 Withholding and Withdrawing Care in the ICU Journal Watch (General), October 30, 1998; 1998(1030): 2 - 2. [Full Text]
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