WITHHOLDING AND WITHDRAWING OF LIFE-SUPPORT FROM PATIENTS WITH SEVEREHEAD-INJURY

Objective: To characterize the withholding or withdrawing of life supp ort from patients with severe head injury. Setting: San Francisco Gene ral Hospital, a city and county hospital with a Level I trauma center. Design: A standardized questionnaire was used to collect data on demo graphics and functional outcome of severely head-injured (Glasgow Coma Score less than or equal to 7) patients admitted to the medical-surgi cal intensive care unit, and to interview the patients' physician and family members. Patients: Forty-seven patients who were admitted to a medical-surgical intensive care unit over a 1-yr period. Interventions : Twenty-four patients had life support withheld or withdrawn, and 23 patients did not. Measurements and Main Results: Physician and family separately assessed patient's probable functional outcome, degree of c ommunication between them, reasons important in recommending or decidi ng on discontinuation of life support, and the result of action taken. Six months later, the families reviewed the process of their decision , how well physician(s) had communicated, and what might have improved communication. Of 24 patients with life support discontinued, 22 died ; two were discharged from the hospital. Twenty-three of the 24 patien ts had a poor prognosis on admission. Of the 23 patients who were cont inued on life support for the duration of their hospitalization, ten h ad a poor (p < .001) prognosis on admission. Prognosis improved for tw o patients from the first group and five from the latter. Family's ass essment of prognosis agreed with physician's assessment in 22 of the 2 4 patients from whom life support was discontinued (p < .001). Physici ans' ability to convey the prognosis appeared to influence families' a ssessments. Physicians' considerations in recommending limitation of c are and families' considerations in making decisions were the same, pr imarily an inevitably poor prognosis. Neither physician nor families c ited cost or availability of care as a deciding factor. Two families d isagreed with the recommendation to limit care after initial agreement because the patients' prognosis improved from ''likely death'' to ''v egetative.'' Care was therefore continued, and both patients remained vegetative 6 months after admission to the hospital and discharge to c hronic care facilities. Conclusions: Life support is commonly withheld or withdrawn from patients with severe head injury at San Francisco G eneral Hospital, and usually it is accompanied by death. A reciprocal consideration exists in most cases between the physician and family ma king the difficult decision to limit care. Care is provided for patien ts whose families request it despite physician recommendations.