Smedira N G, Evans B H, Grais L S, Cohen N H, Lo B, Cooke M, Schecter W P, Fink C, Epstein-Jaffe E, May C
Department of Surgery, University of California, San Francisco.
N Engl J Med. 1990 Feb 1;322(5):309-15. doi: 10.1056/NEJM199002013220506.
We investigated decisions to withhold or withdraw life support from patients in the medical-surgical intensive care units at the Moffitt-Long Hospital of the University of California and San Francisco General Hospital, from July 1987 through June 1988. Among 1719 patients admitted to the two intensive care units, life support was withheld from 22 (1 percent) and withdrawn from 93 (5 percent). The reason for limiting care was poor prognosis. Of these 115 patients (18 of whom were considered brain-dead), 89 died in the intensive care unit (accounting for 45 percent of all deaths there), and all but 1 of the remaining patients died after transfer from the intensive care unit. Thirteen (11 percent) had earlier expressed the wish that their terminal care be limited, but this affected care in only four cases. Only 5 of the 115 patients made the actual decision to limit care; the others were incompetent at the time. Of the latter, 102 had families who participated in the decision; family members of the other 8 incompetent patients could not be found, and the decisions were made by physicians. Only 10 families initially disagreed with the recommendations to limit care, and they later agreed. The median duration of intensive care among the patients from whom life support was withheld or withdrawn was eight days at Moffitt-Long Hospital and four days at San Francisco General, as compared with medians of three and one days, respectively, for other patients who died in the intensive care units. We conclude that although life-sustaining care is withheld or withdrawn relatively infrequently from patients in the intensive care unit, such decisions precipitate about half of all deaths in the intensive care units of the hospitals we studied. In most of these cases the patients are incompetent, but physicians and families usually agree to limit care.
1987年7月至1988年6月期间，我们对加利福尼亚大学莫菲特-朗医院和旧金山总医院内科-外科重症监护病房中关于对患者停止或撤除生命支持的决策进行了调查。在这两个重症监护病房收治的1719例患者中，22例（1%）被停止生命支持，93例（5%）被撤除生命支持。限制治疗的原因是预后不良。在这115例患者（其中18例被认为脑死亡）中，89例在重症监护病房死亡（占该病房所有死亡病例的45%），其余患者除1例之外，均在转出重症监护病房后死亡。13例（11%）患者此前曾表示希望限制其终末期治疗，但这仅在4例中影响了治疗决策。115例患者中只有5例做出了限制治疗的实际决策；其他患者当时无行为能力。在无行为能力的患者中，102例有家属参与决策；另外8例无行为能力患者的家属无法找到，决策由医生做出。最初只有10个家庭不同意限制治疗的建议，但后来他们同意了。在莫菲特-朗医院，被停止或撤除生命支持的患者的重症监护中位时长为8天，在旧金山总医院为4天，而在重症监护病房死亡的其他患者的中位时长分别为3天和1天。我们得出结论，尽管在重症监护病房中对患者停止或撤除维持生命治疗的情况相对较少，但此类决策导致了我们所研究医院重症监护病房中约一半的死亡。在大多数此类病例中，患者无行为能力，但医生和家属通常同意限制治疗。
