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Private attending physician status and the withdrawal of life-sustaining interventions in a medical intensive care unit population

Kollef, Marin H. MD FACP

Clinical Investigation
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Objective  To assess the influence of private attending physician status on the withdrawal of life-sustaining interventions among patients dying within a medical intensive care unit (ICU).

Design  Retrospective cohort analysis.

Setting  An academic tertiary care center.

Patients  One hundred fifty-nine consecutive patient deaths occurring in the medical ICU during a 12-month period.

Interventions  None.

Measurements and Main Results  Withdrawal of life-sustaining interventions (i.e., mechanical ventilation, dialysis, and/or vasopressors), duration of mechanical ventilation, length of intensive care unit stay, medical care costs, and patient charges were recorded.

Life-sustaining interventions were actively withdrawn from 69 (43.4%) patients prior to death. Patients without a private attending physician were significantly more likely to undergo the withdrawal of life-sustaining interventions compared with patients having a private attending physician (odds ratio equals 2.5; 95% confidence interval equals 1.8, 3.6, respectively; p equals .005). A correlation was found between the possession of private health insurance and private attending physician status (r2 equals .39, p less than .001). Multiple logistic regression analysis was subsequently used to control for demographic factors and severity of illness. Three independent predictors for the withdrawal of life-sustaining interventions were identified in this patient cohort (p less than .05): having a planned therapeutic trial of life-sustaining interventions outlined in the medical record (adjusted odds ratio equals 9.4; 95% confidence interval equals 5.6 to 15.6; p less than .001); lack of a private attending physician (adjusted odds ratio equals 4.4; 95% confidence interval equals 2.9 to 6.5; p less than .001); and the presence of clearly defined advance directives regarding patient preferences for medical care (adjusted odds ratio equals 3.6; 95% confidence interval equals 2.3 to 5.7; p equals .005). Patients with private attending physicians had significantly greater medical care costs and medical care charges compared with patients without a private attending physician.

Conclusion  Among patients dying within a medical ICU, those patients without a private attending physician are more likely to undergo the active withdrawal of life-sustaining interventions.

(Crit Care Med 1996; 24:968-975)

From the Pulmonary and Critical Care Division, Department of Internal Medicine, Washington University School of Medicine. St. Louis, MO.

Supported, in part, by the institution's departmental funds.

Address requests for reprints to: Marin H. Kollef, MD, Pulmonary and Critical Care Division, Department of Internal Medicine, Washington University School of Medicine, Box 8052, 660 S. Euclid Avenue, St. Louis, MO 63110.

© Williams & Wilkins 1996. All Rights Reserved.