Life support in the intensive care unit: a qualitative investigation of technological purposes

Background: The ability of many intensive care unit (ICU) technologies to p rolong life has led to an outcomes-oriented approach to technology assessme nt, focusing on morbidity and mortality as clinically important end paints. With advanced life support, however, the therapeutic goals sometimes shift from extending life to allowing life to end. The objective of this study w as to understand the purposes for which advanced life support is withheld, provided, continued or withdrawn in the ICU. Methods: In a 15-bed ICU in a university-affiliate hospital, the authors ob served 25 rounds and 11 family meetings in which withdrawal or withholding of advanced life support was addressed. Semi-structured interviews were con ducted with 7 intensivists, 5 consultants, 9 ICU nurses, the ICU nutritioni st, the hospital ethicist and 3 pastoral services representatives, to discu ss patients about whom life support decisions were made and to discuss life -support practices in general. interview transcripts and field notes were a nalysed inductively to identify and corroborate emerging themes; data were coded following modified grounded theory techniques. Triangulation methods included corroboration among multiple sources of data, multidisciplinary te am consensus, sharing of results with participants and theory triangulation . Results: Although life-support technologies are traditionally deployed to t reat morbidity and delay mortality in ICU patients, they are also used to o rchestrate dying. Advanced life support can be withheld or withdrawn to hel p determine prognosis. The tempo of withdrawal influences the method and ti ming of death. Decisions to withhold, provide, continue or withdraw life su pport are socially negotiated to synchronize understanding and expectations among family members and clinicians. In discussions, one discrete life sup port technology is sometimes used as an archetype for the more general conc ept of technology. At other times, life-support technologies are discussed collectively to clarify the pursuit of appropriate goals of care. Conclusions: The orchestration of death involves process-oriented as well a s outcome-oriented uses of technology. These uses should be considered in t he assessment of life-support technologies and directives for their appropr iate use in the ICU.