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Determinants in Canadian Health Care Workers of the Decision to Withdraw Life Support From the Critically Ill
Deborah J. Cook, MD, MSc;
Gordon H. Guyatt, MD, MSc;
Roman Jaeschke, MD, MSc;
Joan Reeve, RN;
Allen Spanier, MD;
Derek King, BMath;
D. Willie Molloy, MD;
Andrew Willan, PhD;
David L. Streiner, PhD;
Canadian Critical Care Trials Group;
D. J. Cook;
M. Tweeddale, MD;
C. Bradley, PhD;
V. Eliopoulos, RN;
M. L. Hales, RN;
K. Boroomand, MD;
V. Berstein, MD;
C. Mackenzie, RN;
S. Wannamaker, RN;
D. E. Stollery, MD;
M. Anderson, RN;
Hamilton, MD;
R. Johnston, MD;
M.K. Heule, MD;
D. Roberts, MD;
S. Bodnar, RN;
L. Pronger, RN;
B. Light, MD;
K. O'Rourke, RN;
J. Thomas, RN;
G. Diehl, MD;
S. Ihme, RN;
A. Kirby, MD;
K. Perkin, RN;
R. Wexler, MD;
L. Robinson, RN, MScN;
F. Rutledge, MD;
G. Janus, RN;
K. Petti, RN;
J. Kojlak, RN;
C. Hamielec, MD;
R. Santucci, RN;
P. Powles, MD;
H. Fuller, MD;
P. Upton, RN;
J. Hewson, MD;
A. Kidd, RN;
A. Grilli, RN;
A. P. McLellan, MD;
M. Miller, RN;
G. Buczko, MD;
M. Cassidy, RN;
E. Ferris, RN;
S. R. Reid, MD;
M. Burke, RN;
N. Lazar, MD;
M. Medaglia, RN;
C. McLeod, RN;
P. Houston, MD;
A. Hall, RN;
R. Hyland, MD;
I. Ip, RN;
L. Hulton, RN;
B. Mahon, RN;
S. Moffatt, MD;
J. Menard, RN;
R. McIntyre, MD;
J. Armstrong, RN;
S. Izzi, RN;
G. Jones, MD;
W. Fortier, RN;
A. Spanier, MD;
D. Fleiszer, MD;
C. Stone, RN;
J. Boyer, RN;
M. Piccirilli, RN;
P. LaRiccia, RN;
S. Magder, MD;
F. Beauchamps, RN;
N. Desbiens, RN;
L. DiLorenzo, MD;
J. Quesnel, RN;
J. Bilodeau, RN;
C. Pelletier, RN;
A. R. MacNeil, MD;
R. Hall, MD;
C. Hay, RN;
C. Aquino-Russell, RN;
P. Wong, RN;
C. Fraser, RN;
P. Poirier, RN;
S. Peters, MD;
C. Kunz, RN;
E. Warren, RN;
D. J. Cook;
G. H. Guyatt, MD;
R. Jaeschke, MD;
D. W. Molloy, MD;
J. Reeve,, RN;
D. R. King, BMath;
A. Willan, PhD;
D. L. Streiner, PhD;
G. Jones, MD;
A. Spanier, MD;
D. J. Cook, MD;
G. H. Guyatt, MD;
A. Willan, PhD;
D. Maddock;
L. Buckingham;
D. R. King, BMath;
E. Ling, MD;
B. K. Reeve;
S. Reeve
JAMA. 1995;273(9):703-708.
Abstract
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Objective.
—To examine the attitudes of health care workers regarding the withdrawal of life support.
Design.
—Cross-sectional survey.
Participants.
—Attending staff, house staff, and intensive care unit (ICU) nurses in 37 Canadian university-affiliated hospitals.
Main Outcome Measures.
—Health care workers' ratings of the importance of 17 factors considered in the decision to withdraw life support, and their ratings of five levels of care ranging from comfort measures to intensive care in two of 12 different clinical scenarios.
Results.
—We surveyed 1361 respondents (149 of 167 potentially eligible ICU attending staff, 142 of 173 ICU house staff, and 1070 of 1455 ICU nurses, with response rates of 89%, 82% and 74%, respectively). The most important factors were likelihood of surviving the current episode, likelihood of long-term survival, premorbid cognitive function, and age of the patient. In choosing the level of care for the patient scenarios, the same option was chosen by more than 50% of respondents in only one of 12 scenarios; opposite extremes of care were chosen by more than 10% of the respondents in eight of 12 scenarios. Respondent characteristics affecting choices included the number of years since graduation, the city and province in which they worked, the number of beds in their ICU, and their assessment of the likelihood that they would withdraw life support in comparison with their colleagues (P<.001 for all comparisons).
Conclusions.
—While ICU health care workers consistently identify a number of patient factors as important in decisions to withdraw care, there is extreme variability, which may be explained in part by the values of individual health care providers.
(JAMA. 1995;273:703-708)
Author Affiliations
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St. Joseph's Hospital, Hamilton, Ontario.; British Columbia Health Sciences Centre, Vancouver General Hospital, Vancouver, British Columbia; St. Paul's Hospital, Vancouver, British Columbia; University Hospital, Shaughnessy, Vancouver, British Columbia; University Hospital, UBC Site, Vancouver, British Columbia; Grey Nun's Hospital, Edmonton, Alberta; University of Alberta Hospital, Edmonton; Royal Alexandra Hospital, Edmonton, Alberta; Misericordia Hospital, Edmonton, Alberta; Health Science Centre, Winnipeg, Manitoba; St. Boniface General Hospital, Winnipeg, Manitoba; Misericordia General Hospital, Winnipeg, Manitoba; St. Joseph's Health Centre, London, Ontario; University Hospital, London, Ontario; Victoria Hospital, London, Ontario; McMaster University Medical Centre, Hamilton, Ontario; St. Joseph's Hospital, Hamilton, Ontario; Hamilton General Hospital, Hamilton, Ontario; Henderson Hospital, Hamilton, Ontario; St. Michael's Hospital, Toronto, Ontario; Sunnybrook Medical Centre, Toronto, Ontario; The Toronto Hospital, Toronto General Division, Toronto, Ontario; The Toronto Hospital, Toronto Western Division, Toronto, Ontario; The Wellesley Hospital, Toronto, Ontario; Hotel Dieu Hospital, Kingston, Ontario; Kingston General Hospital, Kingston, Ontario; Ottawa Civic Hospital, Ottawa, Ontario; Ottawa General Hospital, Ottawa, Ontario); Jewish General Hospital, Montreal, Quebec; The Montreal General Hospital, Montreal, Quebec; Royal Victoria Hospital, Montreal, Quebec; Hotel-Dieu de Montreal, Montreal, Quebec; Hopital Saint-Luc, Montreal, Quebec; Hopital SainteJustine, Montreal, Quebec; Hopital du Sacre-Coeur de Montreal, Montreal, Quebec; Victoria General Hospital, Halifax, Nova Scotia; Halifax Infirmary, Halifax, Nova Scotia; Health Sciences Centre, St. John's, Newfoundland.; McMaster University Faculty of Health Sciences, Hamilton, Ontario; Ottawa General Hospital, Ottawa, Ontario; Jewish General Hospital, Montreal, Quebec.; McMaster University Faculty of Health Sciences, Hamilton, Ontario.
From the Departments of Medicine (Drs Cook, Guyatt, Jaeschke, and Molloy, and Ms Reeve) and Clinical Epidemiology and Biostatistics (Drs Cook, Guyatt, Willan, and Streiner, and Mr King), McMaster University Faculty of Health Sciences, Hamilton, Ontario; and the Department of Surgery, Jewish General Hospital, McGill University, Montreal, Quebec (Dr Spanier). A complete list of the Canadian Critical Care Trials Group appears at the end of this article.
Footnotes
This work was conducted at McMaster University in Hamilton, Ontario. Drs Cook and Molloy are Career Scientists of the Ontario Ministry of Health.
Reprint requests to Department of Medicine, Division of Critical Care, Fontbonne Bldg, St. Joseph's Hospital, 50 Charlton Ave E, Hamilton, Ontario, Canada L8N 4A6 (Dr Cook).
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