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Ethical and Practice Implications

Kathy Faber-Langendoen, MD

Arch Intern Med. 1996;156(18):2130-2136.

Abstract
Background
Relatively little attention has been paid to how physicians care for dying patients once an initial decision to forgo life-sustaining treatment is made.

Objectives
To describe characteristics of patients forgoing treatment, determine the range and sequential process of forgoing treatment, and suggest ethical and practice implications.

Methods
Charts of 75 consecutive patients dying at each of 4 hospitals were reviewed for this case series. Two hundred ninety-one (98%) of 297 charts were available for review; 274 patients died in acute care beds and are included in this study. Data collected included patients' diagnoses, mental statuses, lengths of stay, timing of the first decision to forgo treatment, and range and sequence of interventions forgone.

Main Outcome Measures
Proportion forgoing life-sustaining treatment, number of interventions forgone

and decision times per patient, and ranked order of treatment withdrawal.

Results
Two hundred twenty-nine (84%) of 274 patients who died had some intervention forgone before death. Only 35% of patients forgoing life-sustaining treatment were able to participate in decision making. On average, 3.8 interventions were forgone per patient. Resuscitation and/or intubation were generally the first measures withheld; once a patient required ventilatory support, withdrawing ventilatory support was a late decision.

Conclusions
The majority of patients dying at these institutions did so after decisions to limit treatment, but few patients were able to participate in these decisions. Forgoing life-sustaining treatment generally occurred in a sequential manner over several days; the rationale for this stepwise retreat is not, however, clinically or ethically obvious.

Arch Intern Med. 1996;156:2130-2136

Author Affiliations
From the Center for Biomedical Ethics, University of Minnesota, Division of Medical Oncology, and Department of Medicine, University of Minnesota Health Sciences Center, Minneapolis.

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