The sequence of withdrawing life-sustaining treatment from patients

PURPOSE: To describe the observed sequence of withdrawal of eight different forms of life-sustaining treatment and to determine whether aspects of tho se treatments determine the order of withdrawal. SUBJECTS AND METHODS: We observed 211 consecutive patients dying in four mi dwestern US hospitals from whom at least one of eight specific life-sustain ing treatments was or could have been withdrawn. We used a parametric stati stical technique to explain the order of withdrawal based on selected chara cteristics of the forms of life support, including cost, scarcity, and disc omfort. RESULTS: The eight forms of life support were withdrawn in a distinct seque nce. From earliest to latest, the order was blood products, hemodialysis, v asopressors, mechanical ventilation, total parenteral nutrition, antibiotic s, intravenous fluids, and tube feedings (P <0.0001). The sequence was almo st identical to that observed in a previous study based on hypothetical sce narios. Forms of life support that were perceived as more artificial, scarc e, or expensive were withdrawn earlier. CONCLUSION: The preference for withdrawing some forms of life-sustaining tr eatments more than others is associated with intrinsic characteristics of t hese treatments. Once the decision has been made to forgo life-sustaining t reatment, the process remains complex and appears to target many different goals simultaneously. (C) 1999 by Excerpta Medica, Inc.