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Cited by 434Palliative Care and End-of-Life IssuesRespiratory Support and MechanismsEthics and Legal Issues in Pediatric Healthcare

Withdrawal of Mechanical Ventilation in Anticipation of Death in the Intensive Care Unit

Cook, Deborah, Rocker, Graeme, Marshall, John, Sjokvist, Peter, Dodek, Peter, Griffith, Lauren, Freitag, Andreas, Varon, Joseph +8 more·2003·New England Journal of Medicine
DOI 10.1056/nejmoa030083
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Abstract

BACKGROUND: In critically ill patients who are receiving mechanical ventilation, the factors associated with physicians' decisions to withdraw ventilation in anticipation of death are unclear. The objective of this study was to examine the clinical determinants that were associated with the withdrawal of mechanical ventilation. METHODS: We studied adults who were receiving mechanical ventilation in 15 intensive care units, recording base-line physiological characteristics, daily Multiple Organ Dysfunction Scores, the patient's decision-making ability, the type of life support administered, the use of do-not-resuscitate orders, the physician's prediction of the patient's status, and the physician's perceptions of the patient's preferences about the use of life support. We examined the relation between these factors and withdrawal of mechanical ventilation, using Cox proportional-hazards regression analysis. RESULTS: Of 851 patients who were receiving mechanical ventilation, 539 (63.3 percent) were successfully weaned, 146 (17.2 percent) died while receiving mechanical ventilation, and 166 (19.5 percent) had mechanical ventilation withdrawn. The need for inotropes or vasopressors was associated with withdrawal of the ventilator (hazard ratio, 1.78; 95 percent confidence interval, 1.20 to 2.66; P=0.004), as were the physician's prediction that the patient's likelihood of survival in the intensive care unit was less than 10 percent (hazard ratio, 3.49; 95 percent confidence interval, 1.39 to 8.79; P=0.002), the physician's prediction that future cognitive function would be severely impaired (hazard ratio, 2.51; 95 percent confidence interval, 1.28 to 4.94; P=0.04), and the physician's perception that the patient did not want life support used (hazard ratio, 4.19; 95 percent confidence interval, 2.57 to 6.81; P<0.001). CONCLUSIONS: Rather than age or the severity of the illness and organ dysfunction, the strongest determinants of the withdrawal of ventilation in critically ill patients were the physician's perception that the patient preferred not to use life support, the physician's predictions of a low likelihood of survival in the intensive care unit and a high likelihood of poor cognitive function, and the use of inotropes or vasopressors.

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Crossref · 10.1056/nejmoa030083

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  • The contradiction between surrogates' aggressive choices and their own understanding of patient preferences may reflect confusion of personal and patient perspectives, conflation of medical care intensity and quality, prioritization of immediate patient well-being over likely long-term outcome, reluctance in the face of prognostic uncertainty to consider withdrawal of a treatment that will likely,

    “This contradiction may reflect confusion of personal and patient perspectives (39), conflation of medical care intensity and quality (40), prioritization of immediate patient well-being over likely long-term outcome (41), reluctance in the face of prognostic uncertainty to consider withdrawal of a treatment that will likely result in death (42), or simply an inadequate mechanization of the values”

    From Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation (2019) · cites this paper as [42]

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Authors
Cook, D., Rocker, G., Marshall, J., Sjokvist, P., Dodek, P., Griffith, L., Freitag, A., Varon, J., Bradley, C., Levy, M., Finfer, S., Hamielec, C., McMullin, J., Weaver, B., Walter, S., & Guyatt, G.
Affiliations
  • McMaster University (CA)
  • Dalhousie University (CA)
  • University of Toronto (CA)
  • University of British Columbia (CA)
  • Brown University (US)
  • The University of Sydney (AU)
ORCID
Venue
New England Journal of Medicine
Publisher
Massachusetts Medical Society
Published
2003-09-18
Volume
349
Issue
12
Pages
1123-1132
ISSN
  • 0028-4793 (ISSN-L)
  • 1533-4406
DOI
10.1056/nejmoa030083
OpenAlex
W2074546317
Cited by
434
References
43
Citations by year
2026: 6 · 2025: 9 · 2024: 6 · 2023: 11 · 2022: 7 · 2021: 5 · 2020: 19 · 2019: 14 · 2018: 10 · 2017: 15 · 2016: 23 · 2015: 19 · 2014: 32 · 2013: 21 · 2012: 20
FWCI
28.44
Type
journal article
Language
en
Open access
closed
Locations
  • New England Journal of Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • DigitalGeorgetown (Georgetown University Library) (submittedVersion)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Ethics and Legal Issues in Pediatric Healthcare
Keywords
mechanical ventilation withdrawal, end-of-life decisions, inotropic agents, vasopressors, cognitive impairment, do-not-resuscitate orders, multiple organ dysfunction score, weaning from mechanical ventilation, intensive care unit, life support
MeSH terms
Adult, Age Factors, Aged, Analysis of Variance, Cardiotonic Agents, Decision Making, Female, Humans, Intensive Care Units, Life Support Care, Male, Middle Aged, Professional-Family Relations, Prospective Studies, Regression Analysis, Respiration, Artificial, Severity of Illness Index, Vasoconstrictor Agents, Ventilator Weaning, Advance Directives, Critical Illness, Outcome Assessment, Health Care, Withholding Treatment

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