Most deaths in intensive care units occur after decisions to limit or withdraw life support [
- Vincent J.L
- Parquier J.N
- Preiser J.C
- Brimioulle S
- Kahn R.J
Terminal events in the intensive care unit: review of 258 fatal cases in one year.
Crit Care Med. 1989; 17: 530-533
2]. Despite an extensive literature on whether to withdraw life support, little attention has been given to how to withdraw it [
- Prendergast T.J
- Luce J.M
Increasing incidence of withholding and withdrawal of life support from the critically ill.
Am J Respir Crit Care Med. 1997; 155: 15-20
- Grenvik A
Terminal weaning”; discontinuance of life-support therapy in the terminally ill patient.
Crit Care Med. 1983; 11: 394-395
4]. For example, a recent edition of a critical care textbook exhaustively covers the ethical and legal aspects of life-support withdrawal, but makes no recommendations for carrying it out [
- Faber-Langendoen K
- Bartels D.M
Process of forgoing life-sustaining treatment in a university hospital: an empirical study.
Crit Care Med. 1992; 20: 570-577
]. Only recently, in the wake of growing data that problems may exist in providing palliative care in the intensive care unit (ICU), has attention been directed to the practical aspects of withdrawing life support [
- Hall J
- Schmidt G
- Wood L
Principles of critical care. McGraw-Hill, New York1992
- Brody H
- Campbell M.L
- Faber-Langendoen K
- Ogle K.S
Withdrawing intensive life-sustaining treatment—recommendations for compassionate clinical management.
N Engl J Med. 1997; 336: 652-657
Curtis J.R Rubenfeld G.D Managing death in the ICU: the transition from cure to comfort. Oxford University Press, New York2000
8]. Many practical questions about withdrawal of life support, and specifically about the withdrawal of mechanical ventilation, are perplexing and controversial: Should the endotracheal tube be left in place? Should the ventilator be weaned slowly or quickly? When and how should sedation be increased? How can the concerns about relieving suffering be reconciled with fears of killing the patient? Should neuromuscular blockade be discontinued? These questions are important because clinicians face them frequently and are still confused by the goals and process of withdrawing life support, and because patients who die after withdrawal of life support may receive inadequate pain and symptom management [
- Campbell M.L
Forgoing life-sustaining therapy: how to care for the patient who is near death. AACN Critical Care, Aliso Viejo (CA)1998
- Asch D.A
The role of critical care nurses in euthanasia and assisted suicide.
N Engl J Med. 1996; 334: 1374-1379
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). The SUPPORT Principal Investigators.
JAMA. 1995; 274: 1591-1598
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