Life Support for Patients without a Surrogate Decision Maker: Who Decides?

3 July 2007 | Volume 147 Issue 1 | Pages 34-40

Background: Physicians in intensive care units have withdrawn life support in incapacitated patients who lack surrogate decision makers and advance directives, yet little is known about how often this occurs or under what circumstances.

Objective: To determine the proportion of deaths in intensive care units that occur in patients who lack decision-making capacity and a surrogate and the process that physicians use to make these decisions.

Design: Multicenter, prospective cohort study.

Setting: Intensive care units of 7 medical centers in 2004 to 2005.

Patients: 3011 consecutive critically ill adults.

Measurements: Attending physicians completed a questionnaire about the decision-making process for each incapacitated patient without a surrogate or advance directive for whom they considered limiting life support.

Results: Overall, 5.5% (25 of 451 patients) of deaths in intensive care units occurred in incapacitated patients who lacked a surrogate decision maker and an advance directive. This percentage ranged from 0% to 27% across the 7 centers. Physicians considered limiting life support in 37 such patients or would have considered it if a surrogate had been available. In 6 patients, there was prospective hospital review of the decision, and in 1 patient, there was court review. In the remaining 30 patients, the decision was made by the intensive care unit team alone or by the intensive care unit team plus another attending physician. The authors found wide variability in hospital policies, professional society guidelines, and state laws regarding who should make life-support decisions for this patient population. Thirty-six of 37 life-support decisions were made in a manner inconsistent with American College of Physicians guidelines for judicial review.

Limitations: The results are based on physicians' self-reported practices and may not match actual practices. The number of incapacitated patients without surrogates in the study is small.

Conclusions: Incapacitated patients without surrogates accounted for approximately 1 in 20 deaths in intensive care units. Most life-support decisions were made by physicians without institutional or judicial review.

Editors' Notes Context In the United States, what happens to incapacitated patients who lack surrogate decision makers has not been quantified. Contribution This prospective study of 3011 critically ill adults in 7 academically affiliated, geographically diverse intensive care units found that 5.5% of the deaths occurred in patients who lacked a surrogate decision maker and an advance directive. Physicians and unit teams made life-support decisions without a formal hospital or court review for 30 of 37 such patients. Pertinent policies varied widely across hospitals and states. Caution Physicians self-reported information about decision making. Implication Physicians commonly make life-support decisions for patients who lack surrogate decision makers, without formal institutional or judicial review. —The Editors

 

Author and Article Information

From the University of California, San Francisco, and San Francisco General Hospital, San Francisco, California; University of Washington School of Medicine, Seattle, Washington; Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; University of Pennsylvania, Philadelphia, Pennsylvania; Oregon Health and Science University, Portland, Oregon; and Beth Israel Medical Center, New York, New York.

Acknowledgments: The authors thank Sandra Kaplan, BSN, and Barbara Finkel, MSN, for assistance with data collection.

Grant Support: By National Institutes of Health grants KL2 RR024130 from the National Center for Research Resources, a component of the National Institutes of Health Roadmap for Medical Research (Dr. White); K24 HL 68593 (Dr. Curtis); and MH 42459 (Ms. Lo). Ms. Lo and Dr. Wolf were also supported by the Greenwall Foundation.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Douglas B. White, MD, MAS, University of California, San Francisco, Program in Medical Ethics, 521 Parnassus Avenue, Suite C-126, Box 0903, San Francisco, CA 94143-0903; e-mail, dwhite{at}medicine.ucsf.edu.

Current Author Addresses: Drs. White and Lo and Ms. Wolf: University of California, San Francisco, Program in Medical Ethics, 521 Parnassus Avenue, Suite C-126, Box 0903, San Francisco, CA 94143-0903.

Dr. Curtis: University of Washington Harborview Medical Center, Box 359762, 325 Ninth Avenue, Seattle, WA 98104.

Dr. Prendergast: Dartmouth–Hitchcock Medical Center, 5-C One Medical Center Drive, Lebanon, NH 03756.

Dr. Taichman: Pulmonary, Allergy and Critical Care Division, University of Pennsylvania School of Medicine, University of Pennsylvania Medical Center–Presbyterian, Suite 441, 39th Street and Market Street, Philadelphia, PA 19104.

Dr. Kuniyoshi: Oregon Health Sciences University, Veterans Affairs Medical Center, 3710 Southwest US Veterans Hospital Road, Portland, OR 97207.

Dr. Acerra: Division of Pulmonary and Critical Care Medicine, Beth Israel Medical Center, First Avenue at 16th Street, New York, NY 10003.

Dr. Luce: Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, 1001 Potrero Avenue, Room 5 K1, San Francisco, CA 94110.

Author Contributions: Conception and design: D.B. White, J.R. Curtis, T.J. Prendergast, D.B. Taichman, B. Lo, J.M. Luce.

Analysis and interpretation of the data: D.B. White, J.R. Curtis, L.E. Wolf, T.J. Prendergast, J.M. Luce.

Drafting of the article: D.B. White, T.J. Prendergast, B. Lo, J.M. Luce.

Critical revision of the article for important intellectual content: D.B. White, J.R. Curtis, L.E. Wolf, T.J. Prendergast, D.B. Taichman, B. Lo.

Final approval of the article: D.B. White, J.R. Curtis, L.E. Wolf, B. Lo, J.M. Luce.

Provision of study materials or patients: J.R. Curtis, T.J. Prendergast, D.B. Taichman, G. Kuniyoshi, F. Acerra, J.M. Luce.

Statistical expertise: D.B. White, J.R. Curtis.

Obtaining of funding: D.B. White, J.R. Curtis.

Administrative, technical, or logistic support: D.B. White, B. Lo, J.M. Luce.

Collection and assembly of data: D.B. White, J.R. Curtis, L.E. Wolf, T.J. Prendergast.

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