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Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers*

White, Douglas B. MD; Curtis, J Randall MD, MPH; Lo, Bernard MD; Luce, John M. MD

doi: 10.1097/01.CCM.0000227654.38708.C1
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Objective: Many intensive care unit (ICU) physicians have withdrawn life-support from a patient who lacked decision-making capacity and a surrogate decision-maker, yet little is known about the decision-making practices for these patients. We sought to determine how often such patients are admitted to the ICU of a metropolitan hospital and how end-of-life decisions are made for them.

Design: Prospective, observational cohort study.

Patients and Setting: Consecutive adult patients admitted to the medical ICU of a metropolitan West Coast hospital during a 7-month period in 2003 to 2004.

Measurements: Attending physicians completed a questionnaire about the decision-making process for each patient for whom they considered limiting life-support who lacked decisional capacity and a legally recognized surrogate decision-maker.

Main Results: Of the 303 patients admitted during the study period, 49 (16%; 95% confidence interval [CI], 12–21%) lacked decision-making capacity and a surrogate during the entire ICU stay. Compared with all other ICU patients, these patients were more likely to be male (88% vs. 69%; p = .002), white (42% vs. 23%; p = .028), and ≥65 yrs old (29% vs. 13%; p = .007). Physicians considered withholding or withdrawing treatment from 37% (18) of the 49 patients who lacked both decision-making capacity and a surrogate decision-maker. For 56% (10) of these 18 patients, the opinion of another attending physician was obtained; for 33% (6 of 18), the ICU team made the decision independently, and for 11% (2 of 18), the input of the courts or the hospital ethics committee was obtained. Overall, 27% of deaths (13 of 49) during the study period were in incapacitated patients who lacked a surrogate (95% CI, 15–41%).

Conclusions: Sixteen percent of patients admitted to the medical ICU of this hospital lacked both decision-making capacity and a surrogate decision-maker. Decisions to limit life support were generally made by physicians without judicial or institutional review. Further research and debate are needed to develop optimal decision-making strategies for these difficult cases.

From the Division of Pulmonary and Critical Care Medicine, University of California, San Francisco School of Medicine (DBW), San Francisco, CA; Program in Medical Ethics (DBW, BL) and Division of General Internal Medicine (BL), Department of Medicine, University of California, San Francisco; Division of Pulmonary and Critical Care Medicine (JRC), Harborview Medical Center, University of Washington, Seattle, WA; and Division of Pulmonary and Critical Care Medicine (JML), San Francisco General Hospital, San Francisco, CA.

The authors have not disclosed any potential conflicts of interest.

Supported in part by National Institutes of Health grants HL-07185 (to DBW), K24 HL 68593 (to JRC), and MH 42459 (to BL). Dr. Lo was also supported by the Greenwall Foundation.

© 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins