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William C. Wilson, MD; Nicholas G. Smedira, MD; Carol Fink, RN; James A. McDowell, LCSW; John M. Luce, MD

JAMA. 1992;267(7):949-953.

Abstract
Objective.
—To determine why and how sedatives and analgesics are ordered and administered during the withholding and withdrawal of life support from critically ill patients.

Design.
—Prospective case series.

Setting.
—Medical-surgical intensive care units at a county hospital and a university hospital.

Patients.
—Consecutive 1-year sample of 22 patients from whom life support was withheld or withdrawn in one intensive care unit at a county hospital and a random sample of 22 similar patients in the intensive care unit in the university hospital over the same period.

Main Outcome Measures.
—Physicians and nurses were interviewed to determine their reasons for ordering and administering drugs, and medical records were reviewed to document amounts of drugs ordered and administered.

Results.
—Drugs were given to 75% of patients during withholding and withdrawal of life support. Patients who did not receive medication were comatose and considered incapable of benefiting from sedation and analgesia. The median time until death following the initiation of the withholding or withdrawal of life support was 3.5 hours in the patients who received drugs and 1.3 hours in those patients who did not (P, not significant). Physicians ordered drugs to decrease pain in 88% of patients, to decrease anxiety in 85%, to decrease air hunger in 76%, to comfort families in 82%, and to hasten death in 39%; in no instance was hastening death the only reason cited. The amounts of benzodiazepines and opiates averaged 2.2 mg/h of diazepam and 3.3 mg/h of morphine sulfate in the 24 hours before withholding and withdrawal of life support and 9.8 mg/h and 11.2 mg/h in the 24 hours thereafter (P<.025 and P<.001, respectively).

Conclusions.
—Large doses of sedatives and analgesics were ordered primarily to relieve pain and suffering during the withholding and withdrawal of life support, and death was not hastened by drug administration.

(JAMA. 1992;267:949-953)

Author Affiliations
From the Departments of Anesthesia (Drs Wilson and Luce), Surgery (Dr Smedira), Nursing (Ms Fink), Social Work (Mr McDowell), and Medicine (Dr Luce), University of California, San Francisco, and San Francisco General Hospital.

Footnotes
Reprint requests to Chest Service, Room 5K1, San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA 94110 (Dr Luce).

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