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Patients' and Surrogates' Decision-Making Characteristics: Withdrawing, Withholding, and Continuing Life-Sustaining Treatments

Melhado, Lolita W. MSN, ARNP, FNP-BC; Byers, Jacqueline Fowler PhD, RN, NEA-BC, CPHQ, FAAN

Journal of Hospice & Palliative Nursing: January-February 2011 - Volume 13 - Issue 1 - p 16-28
doi: 10.1097/NJH.0b013e3182018f09

This integrated literature review examined clinically relevant evidence and provides insight regarding characteristics of patients and surrogates who withdraw or withhold life-sustaining treatment when faced with end-of-life, decision-making, or medically futile treatment compared with those who continue life-sustaining treatment against clinicians' recommendations. Spiraling healthcare costs and propensity to prolong life in the chronically and critically ill have spurred national debate of end-of-life care in the older adult population. Given the challenges associated with longevity, evaluation of current care practices and research are needed to determine best practice to improve communication for a diverse group with differences in culture, ethnicity, education, language, and family systems that influence decision making at end-of-life. Inclusion and exclusion parameters guided the review; databases searched were CINAHL, MEDLINE, PubMed, PsychINFO, and Cochrane Database of Systematic Reviews. Limits included studies from 1995 to 2010, English language and peer reviewed, yielding 19 articles that met the inclusion criteria and answered the research question. Several characteristics were extracted from the study results and clustered into topics. Awareness of patients' and surrogates' decision-making characteristics and communication styles can help clinicians identify potential barriers and variations in patterns of communication. Initial and ongoing assessments of patients' and surrogates' communication style and characteristics must be incorporated into the plan of care. Knowledge of key decision-making characteristics can be useful in role playing and education for clinicians in the health profession.

Lolita W. Melhado, MSN, ARNP, FNP-BC, is Student in the PhD program at University of Central Florida, Gulf Coast Medical Center, Ft Myers, FL.

Jacqueline Fowler Byers, PhD, RN, NEA-BC, CPHQ, FAAN, is Professor, College of Nursing, University of Central Florida, Orlando, FL.

Address correspondence to Lolita W. Melhado, MSN, ARNP, FNP-BC, 13681 Doctors Way, Ft Myers, FL 33912 (

Research was supported by a Graduate Studies Mentoring Fellowship from the University of Central Florida.

The authors declare no conflict of interest.

© 2011 The Hospice and Palliative Nurses Association