Life Support

Crit Care Clin 20 (2004) 435 – 451

Principles and practice of withdrawing life-sustaining treatments
Gordon D. Rubenfeld, MD MSc
Harborview Medical Center, Division of Pulmonary and Critical Care Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104-2499, USA

Most deaths in intensive care units occur after decisions to limit or withdraw life support [1,2]. Despite an extensive literature on whether to withdraw life support, little attention has been given to how to withdraw it [3,4]. For example, a recent edition of a critical care textbook exhaustively covers the ethical and legal aspects of life-support withdrawal, but makes no recommendations for carrying it out [5]. Only recently, in the wake of growing data that problems may exist in providing palliative care in the intensive care unit (ICU), has attention been directed to the practical aspects of withdrawing life support [6 –8]. Many practical questions about withdrawal of life support, and specifically about the withdrawal of mechanical ventilation, are perplexing and controversial: Should the endotracheal tube be left in place? Should the ventilator be weaned slowly or quickly? When and how should sedation be increased? How can the concerns about relieving suffering be reconciled with fears of killing the patient? Should neuromuscular blockade be discontinued? These questions are important because clinicians face them frequently and are still confused by the goals and process of withdrawing life support, and because patients who die after withdrawal of life support may receive inadequate pain and symptom management [9,10].

Principles of withdrawing mechanical ventilation In this era of evidence-based medicine, there is a lack of data to direct clinicians in the optimal management of the dying critically ill patient. Despite the lack of data on optimal management of some aspects of withdrawing lifesustaining treatment, a general consensus exists on the ethical and clinical

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