Sequencing the withdrawal of life-sustaining treatments

Previous studies have demonstrated that when patients are withdrawn from life-sustaining treatments, these treatments are often withdrawn sequentially, rather than all at once. We observed the sequence of withdrawing life support among 211 consecutive patients dying in four Midwestern United States hospitals from whom at least one of eight specific life-sustaining treatments was or could have been withdrawn. We used a parametric statistical technique to explain the order in which these forms of life support were withdrawn in terms of a set of previously determined characteristics of the forms of life support including, among other characteristics, their cost, scarcity, and discomfort. We found a distinct sequence in which the eight forms of life support were withdrawn in this clinical sample. The observed order was, from earliest to latest: blood products, hemodialysis, vasopressors, mechanical ventilation, total parenteral nutrition, antibiotics, intravenous fluids, tube feedings (p < 0.0001). This sequence is almost identical to that observed in a previous study based on hypothetical scenarios. Those forms of life support perceived as more artificial, scarce, or expensive were withdrawn earlier than those with less of these characteristics. We conclude that the preference for withdrawing some forms of life-sustaining treatments over others is associated with intrinsic characteristics of the forms of life-sustaining treatments themselves. Once the decision has been made to forgo life-sustaining treatment, the process used remains complex and appears to target many different goals simultaneously.