Withdrawing life support and resolution of conflict with families

What is the best way for the intensive care team to work with a family to decide on a plan of care when withdrawing or withholding life support?

A high proportion of deaths in intensive care occur after withdrawal or withholding of life support. In a survey of critical care physicians, 85% of respondents had withheld or withdrawn life support in the preceding year.1 A US study showed a large increase in the proportion of deaths in intensive care that were preceded by a decision to withhold or withdraw life support, from 50% in 1987-88 to over 90% in 1992-93.2 In many countries, most deaths in intensive care are preceded by a decision to withdraw or withhold life support, 3 4^w1-w4 although the proportion of deaths preceded by withdrawal versus withholding varies.4

Although limitation of life support before death is common in most intensive care units, there are wide variations in approaches to end of life care. 5 6^{w1 w5 w6} In a survey of 131 intensive care units in the United States, the proportion of deaths in which life support was withheld varied from 0% to 67% and the proportion of deaths after withdrawal of life support varied from 0% to 79%.5 These wide variations suggest the need for increased consensus on best practices for managing death in intensive care units. In this article, we review the empirical research that can guide physicians in deliberations over whether to withdraw life support, maximising patient and family involvement in the decision making process, and negotiating conflicts that may arise.