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Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative study



Our aim was to explore reasons for physician variability in decisions to limit life support in the intensive care unit (ICU) utilizing qualitative methodology.


Single center study consisting of semi-structured interviews with experienced physicians and nurses. Seventeen intensivists from medical (n = 7), surgical (n = 5), and anesthesia (n = 5) critical care backgrounds, and ten nurses from medical (n = 5) and surgical (n = 5) ICU backgrounds were interviewed. Principles of grounded theory were used to analyze the interview transcripts.


Eleven factors within four categories were identified that influenced physician variability in decisions to limit life support: (1) physician work environment—workload and competing priorities, shift changes and handoffs, and incorporation of nursing input; (2) physician experiences—of unexpected patient survival, and of limiting life support in physician’s family; (3) physician attitudes—investment in a good surgical outcome, specialty perspective, values and beliefs; and (4) physician relationship with patient and family—hearing the patient’s wishes firsthand, engagement in family communication, and family negotiation.


We identified several factors which physicians and nurses perceived were important sources of physician variability in decisions to limit life support. Ways to raise awareness and ameliorate the potentially adverse effects of factors such as workload, competing priorities, shift changes, and handoffs should be explored. Exposing intensivists to long term patient outcomes, formalizing nursing input, providing additional training, and emphasizing firsthand knowledge of patient wishes may improve decision making.

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  1. 1.

    Cook D, 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 (2003) Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 349:1123–1132

  2. 2.

    Azoulay E, Pochard F, Garrouste-Orgeas M, Moreau D, Montesino L, Adrie C, de Lassence A, Cohen Y, Timsit JF (2003) Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death. Intensive Care Med 29:1895–1901

  3. 3.

    Chen YY, Connors AF Jr, Garland A (2008) Effect of decisions to withhold life support on prolonged survival. Chest 133:1312–1318

  4. 4.

    Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J, Adrie C, Annane D, Bleichner G, Bollaert PE, Darmon M, Fassier T, Galliot R, Garrouste-Orgeas M, Goulenok C, Goldgran-Toledano D, Hayon J, Jourdain M, Kaidomar M, Laplace C, Larche J, Liotier J, Papazian L, Poisson C, Reignier J, Saidi F, Schlemmer B (2005) Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 171:987–994

  5. 5.

    Poncet MC, Toullic P, Papazian L, Kentish-Barnes N, Timsit JF, Pochard F, Chevret S, Schlemmer B, Azoulay E (2007) Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med 175:698–704

  6. 6.

    Mealer M, Jones J, Moss M (2012) A qualitative study of resilience and posttraumatic stress disorder in United States ICU nurses. Intensive Care Med 38:1445–1451

  7. 7.

    Quenot JP, Rigaud JP, Prin S, Barbar S, Pavon A, Hamet M, Jacquiot N, Blettery B, Herve C, Charles PE, Moutel G (2012) Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices. Intensive Care Med 38:55–61

  8. 8.

    Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, Hinds C, Pimentel JM, Reinhart K, Thompson BT (2004) Challenges in end-of-life care in the ICU. Statement of the 5th international consensus conference in critical care: Brussels, Belgium, April 2003. Intensive Care Med 30:770–784

  9. 9.

    Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC (2008) Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of critical care medicine. Crit Care Med 36:953–963

  10. 10.

    Garland A, Connors AF (2007) Physicians’ influence over decisions to forego life support. J Palliat Med 10:1298–1305

  11. 11.

    Frost DW, Cook DJ, Heyland DK, Fowler RA (2011) Patient and healthcare professional factors influencing end-of-life decision-making during critical illness: a systematic review. Crit Care Med 39:1174–1189

  12. 12.

    Christakis NA, Asch DA (1993) Biases in how physicians choose to withdraw life support. Lancet 342:624–626

  13. 13.

    Christakis NA, Asch DA (1995) Medical specialists prefer to withdraw familiar technologies when discontinuing life support. J Gen Intern Med 10:491–494

  14. 14.

    Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, Ledoux D, Lippert A, Maia P, Phelan D, Schobersberger W, Wennberg E, Woodcock T (2003) End-of-life practices in European intensive care units: the ethicus study. JAMA 290:790–797

  15. 15.

    Schwarze ML, Bradley CT, Brasel KJ (2010) Surgical “buy-in”: the contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy. Crit Care Med 38:843–848

  16. 16.

    Schwarze ML, Redmann AJ, Alexander GC, Brasel KJ (2013) Surgeons expect patients to buy-into postoperative life support preoperatively: results of a national survey. Crit Care Med 41:1–8

  17. 17.

    Schwarze ML, Redmann AJ, Brasel KJ, Alexander GC (2012) The role of surgeon error in withdrawal of postoperative life support. Ann Surg 256:10–15

  18. 18.

    Schenker Y, Tiver GA, Hong SY, White DB (2012) Association between physicians’ beliefs and the option of comfort care for critically ill patients. Intensive Care Med 38:1607–1615

  19. 19.

    Bulow HH, Sprung CL, Baras M, Carmel S, Svantesson M, Benbenishty J, Maia PA, Beishuizen A, Cohen S, Nalos D (2012) Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The ethicatt study. Intensive Care Med 38:1126–1133

  20. 20.

    Buchman TG, Cassell J, Ray SE, Wax ML (2002) Who should manage the dying patient?: rescue, shame, and the surgical ICU dilemma. J Am Coll Surg 194:665–673

  21. 21.

    Barnato AE, Tate JA, Rodriguez KL, Zickmund SL, Arnold RM (2012) Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity. Intensive Care Med 38:1886–1896

  22. 22.

    Cohen S, Sprung C, Sjokvist P, Lippert A, Ricou B, Baras M, Hovilehto S, Maia P, Phelan D, Reinhart K, Werdan K, Bulow HH, Woodcock T (2005) Communication of end-of-life decisions in European intensive care units. Intensive Care Med 31:1215–1221

  23. 23.

    Levinson W, Kao A, Kuby A, Thisted RA (2005) Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med 20:531–535

  24. 24.

    Redmann AJ, Brasel KJ, Alexander CG, Schwarze ML (2012) Use of advance directives for high-risk operations: a national survey of surgeons. Ann Surg 255:418–423

  25. 25.

    Keenan SP, Busche KD, Chen LM, Esmail R, Inman KJ, Sibbald WJ (1998) Withdrawal and withholding of life support in the intensive care unit: a comparison of teaching and community hospitals. The Southwestern Ontario critical care research network. Crit Care Med 26:245–251

  26. 26.

    Cook DJ, Guyatt GH, Jaeschke R, Reeve J, Spanier A, King D, Molloy DW, Willan A, Streiner DL (1995) Determinants in Canadian health care workers of the decision to withdraw life support from the critically ill. Canadian critical care trials group. JAMA 273:703–708

  27. 27.

    Bewley JSBF, Waters K, Manara AR (2000) The influence of intensive care unit (ICU) workload on decisions to withdraw treatment. Br J Anaesth 84:661–662

  28. 28.

    Wilson ME, Samirat R, Yilmaz M, Gajic O, Iyer VN (2013) Physician staffing models impact the timing of decisions to limit life support in the intensive care unit. Chest 143:656–663

  29. 29.

    Baggs JG, Norton SA, Schmitt MH, Dombeck MT, Sellers CR, Quinn JR (2007) Intensive care unit cultures and end-of-life decision making. J Crit Care 22:159–168

  30. 30.

    Rhodes A, Moreno RP, Azoulay E, Capuzzo M, Chiche JD, Eddleston J, Endacott R, Ferdinande P, Flaatten H, Guidet B, Kuhlen R, Leon-Gil C, Martin Delgado MC, Metnitz PG, Soares M, Sprung CL, Timsit JF, Valentin A (2012) Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the task force on safety and quality of the European society of intensive care medicine (ESICM). Intensive Care Med 38:598–605

  31. 31.

    Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA (2004) Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 351:1838–1848

  32. 32.

    Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ (2000) Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 356:185–189

  33. 33.

    Tucker J (2002) Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation. Lancet 359:99–107

  34. 34.

    Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA (2001) Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection. Crit Care Med 29:753–758

  35. 35.

    Hugonnet S, Chevrolet JC, Pittet D (2007) The effect of workload on infection risk in critically ill patients. Crit Care Med 35:76–81

  36. 36.

    Baker DR, Pronovost PJ, Morlock LL, Geocadin RG, Holzmueller CG (2009) Patient flow variability and unplanned readmissions to an intensive care unit. Crit Care Med 37:2882–2887

  37. 37.

    Nelson JE, Bassett R, Boss RD, Brasel KJ, Campbell ML, Cortez TB, Curtis JR, Lustbader DR, Mulkerin C, Puntillo KA, Ray DE, Weissman DE (2010) Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU project (improving palliative care in the ICU). Crit Care Med 38:1765–1772

  38. 38.

    Maughan BC, Lei L, Cydulka RK (2011) ED handoffs: observed practices and communication errors. Am J Emerg Med 29:502–511

  39. 39.

    Sri D (2012) A telephone survey of intensive care unit handover practices in the UK. Intensive Care Med 38:2080

  40. 40.

    Shanawani H, Wenrich MD, Tonelli MR, Curtis JR (2008) Meeting physicians’ responsibilities in providing end-of-life care. Chest 133:775–786

  41. 41.

    Croskerry P (2005) Diagnostic failure: a cognitive and affective approach. In: Henriksen K BJ, Marks ES, et al. (eds) Advances in patient safety: from research to implementation (volume 2: concepts and methodology). Rockville (MD): Agency for healthcare research and quality, US

  42. 42.

    Nelson JE, Mulkerin CM, Adams LL, Pronovost PJ (2006) Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care 15:264–271

  43. 43.

    Soares M, Piva JP (2012) Physicians just need to be better trained to provide the best care at the end-of-life. Intensive Care Med 38:342–344

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The authors would like to thank J. Randall Curtis MD, MPH for his thoughtful guidance and manuscript review. Financial/non financial disclosures: Financial Support was provided by Mayo Clinic Sponsorship Board and Mayo Foundation.

Conflicts of interest

The authors have no conflicts of interest to disclose.

Author information

Correspondence to Michael E. Wilson.

Electronic supplementary material

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Supplementary material 1 (DOC 40 kb)

Appendix: interview guide questions

Appendix: interview guide questions

For physicians:

  1. 1.

    How do you (or intensivists) make decisions to limit or continue life support?

    1. a.

      What factors influence decisions to limit or continue life support?

For nurses:

  1. 1.

    How do physicians make decisions to limit or continue life support?

    1. a.

      What factors influence decisions to limit or continue life support?

    2. b.

      What is your role as a nurse in making/contributing to decisions about continuing or limiting life support?

For physicians and nurses:

  1. 2.

    Prior research has established that both patient preference and patient prognosis are strong influences in the decision to limit life support. Aside from the patient’s life support preferences and aside from the patient’s prognosis, which other factors influence the decision to limit life support?

  2. 3.

    Why do physicians make varying decisions to limit or continue life support?

    1. a.

      Suppose two different physicians were treating the same patient, what factors would lead different decisions being made?

    2. b.

      Can you give an example?

  3. 4.

    What does it mean to withdraw life support prematurely?

    1. a.

      Can you give an example of when life support was withdrawn prematurely?

    2. b.

      Which factors led to premature withdrawal of life support?

  4. 5.

    What does it mean to continue life support unnecessarily?

    1. a.

      Can you given an example of when life support was continued unnecessarily?

    2. b.

      Which factors led to life support being continued unnecessarily?

  5. 6.

    Have you ever disagreed with another provider about the decision to limit life support?

    1. a.

      Can you give an example of when life support was withdrawn and you disagreed?

    2. b.

      Why did you disagree?

    3. c.

      Can you give an example of when life support was continued and you disagreed?

    4. d.

      Why did you disagree?

  6. 7.

    Have you ever felt regret regarding a decision to limit or continue life support?

  7. 8.

    Describe a situation in which a decision was made to limit life support and the end result was what you believed to be a good outcome.

    1. a.

      What made it a good outcome?

  8. 9.

    Describe a situation in which a decision was made to limit life support and the end result was what you believed to be a poor outcome.

    1. a.

      What made it a poor outcome?

  9. 10.

    What interventions would you propose that could improve life support decision making?

  10. 11.

    Is there anything else you would like to share about this topic?

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Wilson, M.E., Rhudy, L.M., Ballinger, B.A. et al. Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative study. Intensive Care Med 39, 1009–1018 (2013). https://doi.org/10.1007/s00134-013-2896-x

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  • Intensive care
  • Life support care
  • Withholding treatment
  • Decision making
  • Physician’s role
  • Terminal care