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

Background: The objective of this study was to examine the clinical determinants that were associated with the withdrawal of mechanical ventilation.

Design and Participants: Adults in 15 ICUs who were receiving mechanical ventilation were studied, and based on physiological characteristics, daily multiple organ dysfunction scores, patient's decision making ability, the type of life support administered, the use of DNR orders, physician prediction of patient's status, and the physicians perceptions of the patient's preferences of life support was identified, and the relationship between those factors, and withdrawal of mechanical ventilation was studied.

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146 (17.2 percent) died while receiving mechanical ventilation, and 166 (19.5 percent) had mechanical ventilation withdrawn.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).

Commentary: The study found that patients who had the ventilator withdrawn and those who died while receiving mechanical ventilation had a shorter stay in the ICU than patients who were successfully weaned. In contrast, two decades ago, patients who eventually died in the ICU had a longer stay, with greater use of resources, than those who lived. The strongest determinant of withdrawal of ventilation in a critically ill patient, was the physician's perception that the patient preferred not to use life support, predictions of low likelihood of survival and high likelihood of poor cognitive function, rather than the age or severity of the illness, or the organ dysfunction. 

Bottom Line: The findings reflect that ICU's are changing in general, and are addressing goals of care earlier than what was done prior.

Cook, Deborah, et al. "Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit." New England Journal of Medicine 349.12 (2003): 1123-1132.