Skip to main content
SpringerLink
Log in

Clinician discomfort with life support plans for mechanically ventilated patients

  • Original
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Objective

To examine the incidence and predictors of clinician discomfort with life support plans for ICU patients.

Design and setting

Prospective cohort in 13 medical-surgical ICUs in four countries.

Patients

657 mechanically ventilated adults expected to stay in ICU at least 72 h.

Measurements and results

Daily we documented the life support plan for mechanical ventilation, inotropes and dialysis, and clinician comfort with these plans. If uncomfortable, clinicians stated whether the plan was too technologically intense (the provision of too many life support modalities or the provision of any modality for too long) or not intense enough, and why. At least one clinician was uncomfortable at least once for 283 (43.1%) patients, primarily because plans were too technologically intense rather than not intense enough (93.9% vs. 6.1%). Predictors of discomfort because plans were too intense were: patient age, medical admission, APACHE II score, poor prior functional status, organ dysfunction, dialysis in ICU, plan to withhold dialysis, plan to withhold mechanical ventilation, first week in the ICU, clinician, and city.

Conclusions

Clinician discomfort with life support perceived as too technologically intense is common, experienced mostly by nurses, variable across centers, and is more likely for older, severely ill medical patients, those with acute renal failure, and patients lacking plans to forgo reintubation and ventilation. Acknowledging the sources of discomfort could improve communication and decision making

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Rubenfeld GD, Curtis JR, for the End-of-Life Care in the ICU Working Group (2001) End-of-life care in the intensive care unit: a research agenda. Crit Care Med 29:2001–2006

    Article  CAS  PubMed  Google Scholar 

  2. Breen CM, Abernethy AP, Abbott KH, Tulsky JA (2001) Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med 16:283–289

    Article  CAS  PubMed  Google Scholar 

  3. Prendergast TJ, Luce JM (1997) Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med 155:15–20

    CAS  PubMed  Google Scholar 

  4. Cook DJ, 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 GH, for the Level of Care Study Investigators and the Canadian Critical Care Trials Group (2003) Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 349:1123–1132

    Article  CAS  PubMed  Google Scholar 

  5. Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–825

    CAS  PubMed  Google Scholar 

  6. Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ (1995) The Multiple organ Dysfunction (MOD) score: a reliable descriptor of a complex clinical outcome. Crit Care Med 23:1638–1652

    Article  CAS  PubMed  Google Scholar 

  7. Goldstein H (2003) Multilevel statistical models, 3rd edn. Hodder Arnold. London

  8. Singer JD (1998) Using SAS PROC MIXED to fix multilevel models, hierarchical models, and individual growth models. J Educ Behav Stat 24:323–355

    Google Scholar 

  9. Wolfinger R, O’Connell M (1993) Generalized linear mixed models: a pseudo-likelihood approach. J Stat Comput Simul 48:233–243

    Google Scholar 

  10. Guerin C, Raphaele G, Selli J, Perdrix J, Ayzac L, for the Rhone-Alps Area Study Group on Acute Renal Failure (2000) Initial versus delayed acute renal failure in the intensive care unit. Am J Respir Crit Care Med 161:872–879

    CAS  PubMed  Google Scholar 

  11. Asch DA, Christakis NA (1996) Why do physicians prefer to withdraw some form of life support over others? Intrinsic attributes of life-sustaining treatments are associated with physicians’ preferences. Med Care 34:103–111

    Article  CAS  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  13. Elstein AS, Christensen C, Cottrell JJ, Polson A, Ng M (1999) Effects of prognosis, perceived benefit, and decision style on decision making and critical care on decision making in critical care. Crit Care Med 27:58–65

    Article  CAS  PubMed  Google Scholar 

  14. Ferrand E, Lemaire F, Regnier B, Kuteifan K, Badet M, Asfar P, Jaber S, Chagnon JL, Renault A, Robert R, Pochard F, Herve C, Brun-Buisson C, Duraldestin P for the French RESSENTI Group (2003) Discrepancies between perceptions by physicians and nursing staff of intensive care unit end of life decisions. Am J Respir Crit Care Med 167:1310–1315

    Article  PubMed  Google Scholar 

  15. Asch DA (1996) The role of critical care nurses in euthanasia and assisted suicide. N Engl J Med 334:1374–1379

    Article  CAS  PubMed  Google Scholar 

  16. Miller D, Coe RM, Hyers TM (1992) Achieving consensus on withdrawing or withholding care for critically ill patients. J Gen Intern Med 7:475–480

    CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  18. Stevens L, Cook D, Guyatt G, Griffith L, Walter S, McMullin J (2002) Education, ethics, and end-of-life decisions in the intensive care unit. Crit Care Med 30:290–296

    Article  PubMed  Google Scholar 

  19. Danis M, Federman D, Fins JJ, Fox E, Kasterbaum B, Lanken PN, Long K, Lowenstein E, Lynn J, Rouse F, Tulsky J (1999) Incorporating palliative care into critical care education: principles, challenges, and opportunities. Crit Care Med 27:2068–2069

    PubMed  Google Scholar 

  20. Cook DJ, Guyatt G, Rocker G, Sjokvist P, Weaver B, Dodek P, Marshall J, Leasa D, Levy M, Varon J, Fisher M, Cook R, for the Canadian Critical Care Trials group (2001) Cardiopulmonary resuscitation directives on admission to intensive care unit: an international observational study. Lancet 358:1941–1945

    Article  CAS  PubMed  Google Scholar 

  21. Mello M, Jenkinson C (1998) Comparison of medical and nursing attitudes to resuscitation and patient autonomy between a British and American teaching hospital. Soc Sci Med 46:415–424

    Article  CAS  PubMed  Google Scholar 

  22. Vincent JL (1999) Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med 27:1626–1633

    Article  CAS  PubMed  Google Scholar 

  23. Sjokvist P, Cook DJ, Berggren L, Guyatt G (1998) A cross-cultural comparison of attitudes toward life support limitation in Sweden and Canada. Clin Intensive Care 9:81–85

    Google Scholar 

  24. Schneiderman LJ, Gilmer T, Teetzel HD (2000) Impact of ethics consultations in the intensive care setting: a randomized, controlled trial. Crit Care Med 28:3920–3924

    CAS  PubMed  Google Scholar 

  25. Prendergast TJ (1997) Resolving conflicts surrounding end-of-life care. New Horiz 5:62–71

    CAS  PubMed  Google Scholar 

  26. Edwards BS (1993) When the physician won’t give up. Am J Nurs 93:34–37

    CAS  Google Scholar 

Download references

Acknowledgements

We are grateful to the research nurses, bedside nurses, residents, and physicians who participated in this study, and to Ellen McDonald for her help with the coordination. We also thank the Canadian Critical Care Trials Group for their support. Site investigators and research nurses: Peter Dodek, MD, Carol Honeyman, RN (St. Paul’s Hospital, Vancouver, British Columbia); John Marshall, MD, Debra Foster, RN, Chanel McKenna (General Division), Neil Lazar, MD, Marilyn Steinberg, RN (Western Division; Toronto Hospital, Toronto, Ontario); David Leasa, MD, Sue Langdon, RN (University Hospital), Ann Kirby, MD, Mary Katherine Scott, RN, Mary van Soeren, RN (St. Joseph’s Hospital; London Health Sciences Center, London, Ontario); Deborah Cook, MD, Ellen McDonald, RN (Joseph’s Hospital, Hamilton, Ontario); Allan McLellan, Serge Puksa, MD, Andrea Tkaczyk, RN (Henderson Division), Christine Bradley, MD, Nicole Krolicki, RN, Susan Caldwell, RN (General Division), Cindy Hamielec, MD, Nancy Merrill, RN (McMaster Division), (Hamilton Health Sciences Corporation, Hamilton, Ontario); Graeme Rocker, MD, Mary Gordon MacKenzie, PhD (Victoria General Hospital and Halifax Infirmary, Halifax, Nova Scotia); Joseph Varon, MD, Cheryl Keenan, RN (MD Anderson Cancer Center, Houston, Dallas, Texas); Mitchell Levy, MD, Mary Beth Fucci, RN (Rhode Island Hospital, Providence, Rhode Island); Peter Sjokvist, MD, Mia Svantesson, RN (Orebro Hospital, Orebro, Sweden); Simon Finfer, MD, Malcolm Fisher, MD, Joey Penfold, RN, Anne O’Connor, RN (Royal North Shore Hospital, Sydney, Australia). Methods Center: study coordinators: Lisa Buckingham, Nicole Krolicki; database management: Lisa Buckingham; data entry: Suzanne Duchesne, Sandi Reeve, Barbara Jedrzejowski.

Author information

Authors and Affiliations

  1. Departments of Clinical Epidemiology and Biostatistics, Medical Center, McMaster University, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada

    Lauren Griffith, Deborah Cook, Steven Hanna, Lisa Buckingham & Gordon Guyatt

  2. Department of Medicine, Medical Center, McMaster University, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada

    Deborah Cook, Roman Jaeschke & Gordon Guyatt

  3. Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada

    Graeme Rocker

  4. Program of Critical Care Medicine, University of British Columbia, Vancouver, British Columbia, Canada

    Peter Dodek

  5. Department of Surgery, University of Toronto, Toronto, Ontario, Canada

    John Marshall

  6. Department of Medicine, Brown University, Providence, R.I., USA

    Mitchell Levy

  7. Department of Medicine, Baylor College of Medicine, Houston, Tex., USA

    Joseph Varon

  8. Intensive Care Unit, Royal North Shore Hospital, University of Sydney, Sydney, Australia

    Simon Finfer

Authors
  1. Lauren Griffith
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Deborah Cook
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Steven Hanna
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Graeme Rocker
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Peter Sjokvist
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Peter Dodek
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. John Marshall
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Mitchell Levy
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Joseph Varon
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Simon Finfer
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Roman Jaeschke
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Lisa Buckingham
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Gordon Guyatt
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

for the Level of Care Investigators and the Canadian Critical Care Trials Group

Corresponding author

Correspondence to Lauren Griffith.

Additional information

This study was funded by several national and provincial agencies (Medical Research Council of Canada; Department of Health, Province of Nova Scotia; Physicians Services Incorporated of Ontario; British Columbia Medical Services Foundation; and the Research Committee of the Orebro County Council, Sweden) and regional peer-review agencies (Father Sean O’Sullivan Research Centre, St. Joseph’s Hospital; Health Services Research Fund, London Health Sciences Centre; University Internal Medicine Research Fund, Dalhousie University; Faculty of Medicine Intramural Grant, Dalhousie University; Camphill Medical Centre Research Fund, Halifax; and the Queen Elizabeth II Health Sciences Centre Research Fund, Halifax). D.C. is Research Chair of the Canadian Institutes for Health Research.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Griffith, L., Cook, D., Hanna, S. et al. Clinician discomfort with life support plans for mechanically ventilated patients. Intensive Care Med 30, 1783–1790 (2004). https://doi.org/10.1007/s00134-004-2360-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-004-2360-z

Keywords

Search

Navigation