Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit

被引:297
|
作者
Cook, D [1 ]
Rocker, G
Marshall, J
Sjokvist, P
Dodek, P
Griffith, L
Freitag, A
Varon, J
Bradley, C
Levy, M
Finfer, S
Hamielec, C
McMullin, J
Weaver, B
Walter, S
Guyatt, G
机构
[1] McMaster Univ, Dept Med, Hamilton, ON, Canada
[2] McMaster Univ, Dept Clin Epidemiol & Biostat, Hamilton, ON, Canada
[3] Dalhousie Univ, Dept Med, Halifax, NS, Canada
[4] Univ Toronto, Dept Surg, Toronto, ON, Canada
[5] Huddinge Univ, Dept Anesthesia & Intens Care, Stockholm, Sweden
[6] Univ British Columbia, Program Crit Care Med, Vancouver, BC V5Z 1M9, Canada
[7] Baylor Coll Med, Dept Med, Houston, TX 77030 USA
[8] Brown Univ, Dept Med, Providence, RI 02912 USA
[9] Univ Sydney, Royal N Shore Hosp, Intens Therapy Unit, Sydney, NSW 2006, Australia
[10] Toronto Hosp, Toronto, ON M5T 2S8, Canada
[11] London Hlth Sci Ctr, London, ON, Canada
[12] Hamilton Hlth Sci Ctr, Hamilton, ON, Canada
来源
NEW ENGLAND JOURNAL OF MEDICINE | 2003年 / 349卷 / 12期
关键词
D O I
10.1056/NEJMoa030083
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
BACKGROUND: In critically ill patients who are receiving mechanical ventilation, the factors associated with physicians' decisions to withdraw ventilation in anticipation of death are unclear. The objective of this study was to examine the clinical determinants that were associated with the withdrawal of mechanical ventilation. METHODS: We studied adults who were receiving mechanical ventilation in 15 intensive care units, recording base-line physiological characteristics, daily Multiple Organ Dysfunction Scores, the patient's decision-making ability, the type of life support administered, the use of do-not-resuscitate orders, the physician's prediction of the patient's status, and the physician's perceptions of the patient's preferences about the use of life support. We examined the relation between these factors and withdrawal of mechanical ventilation, using Cox proportional-hazards regression analysis. RESULTS: Of 851 patients who were receiving mechanical ventilation, 539 (63.3 percent) were successfully weaned, 146 (17.2 percent) died while receiving mechanical ventilation, and 166 (19.5 percent) had mechanical ventilation withdrawn. The need for inotropes or vasopressors was associated with withdrawal of the ventilator (hazard ratio, 1.78; 95 percent confidence interval, 1.20 to 2.66; P=0.004), as were the physician's prediction that the patient's likelihood of survival in the intensive care unit was less than 10 percent (hazard ratio, 3.49; 95 percent confidence interval, 1.39 to 8.79; P=0.002), the physician's prediction that future cognitive function would be severely impaired (hazard ratio, 2.51; 95 percent confidence interval, 1.28 to 4.94; P=0.04), and the physician's perception that the patient did not want life support used (hazard ratio, 4.19; 95 percent confidence interval, 2.57 to 6.81; P<0.001). CONCLUSIONS: Rather than age or the severity of the illness and organ dysfunction, the strongest determinants of the withdrawal of ventilation in critically ill patients were the physician's perception that the patient preferred not to use life support, the physician's predictions of a low likelihood of survival in the intensive care unit and a high likelihood of poor cognitive function, and the use of inotropes or vasopressors.
引用
收藏
页码:1123 / 1132
页数:10
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