Withdrawing and withholding life support in the intensive care unit: a Spanish prospective multi-centre observational study

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Abstract
Objective: To determine how frequently life support is withheld or withdrawn from adult critically ill patients, and how physicians and patients families agree on the decision regarding the limitation of life support. Design: Prospective multi-centre cohort study. Setting: Six adult medical-surgical Spanish intensive care units (ICUs). Patients and participants: Three thousand four hundred ninety-eight consecutive patients admitted to six ICUs were enrolled. Measurements and results: Data collected included age, sex, SAPS II score on admission and within 24 h of the decision to limit treatment, length of ICU stay, outcome at ICU discharge, cause and mode of death, time to death after the decision to withhold or withdraw life support, consultation and agreement with patient's family regarding withholding or withdrawal, and the modalities of therapies withdrawn or withheld. Two hundred twenty-six (6.6%) of 3,498 patients had therapy withheld or withdrawn and 221 of them died in the ICU. Age, SAPS II and length of ICU stay were significantly higher in patients dying patients who had therapy withheld or withdrawn than in patients dying despite active treatment. The proposal to withhold or withdraw life support was initiated by physicians in 210 (92.9%) of 226 patients and by the family in the remaining cases. The patient's family was not involved in the decision to withhold or withdraw life support therapy in 64 (28.3%) of 226 cases. Only 21 (9%) patients had expressed their wish to decline life-prolonging therapy prior to ICU admission. Conclusions: The withholding and withdrawing of treatment was frequent in critically ill patients and was initiated primarily by physicians.