Changing patterns of terminal care management in an intensive care unit.

OBJECTIVE

To empirically describe changes in terminal care management behavior over time with the advent of natural death acts and public dialogue and institutional policy regarding terminal care.

DESIGN

Retrospective analysis of medical decision-making and outcome was performed in a cohort of 237 intensive care unit (ICU) patients who received a do-not-resuscitate decision.

SETTING

Medical ICU in a tertiary care center.

PATIENTS

The cohort of 237 consecutive patients who received a terminal care decision in the ICU, i.e., a do-not-resuscitate decision with or without additional limitation of care, represented 9.3% of 2,185 patients admitted to the ICU over a 4-yr period. Brain-dead patients were excluded from the cohort.

INTERVENTIONS

Implementation of hospital-wide policies on do-not-resuscitate decisions and discontinuation of life-prolonging procedures in 1986.

MEASUREMENTS AND MAIN RESULTS

A change in frequency and nature of terminal care decisions occurred. By 1988, do-not-resuscitate decisions occurred twice as often as in 1984 (p = .016) compared with ICU deaths. Formal terminal wean decisions, i.e., additional limitation or withdrawal of care, occurred more frequently after 1985 (p = .027). The hospital mortality rate for the do-not-resuscitate cohort was 96.4% (226/237). The diagnosis of cardiac arrest was correlated with subsequent terminal care decisions (p = .0005, r2 = .08). Age of >56 yrs was increasingly correlated with probability of a terminal care decision (p < .0001, r2 = .05). White women received withdrawal of care most frequently, followed by white men, African American men, and African American women. Outcomes analysis indicated that after a do-not-resuscitate decision, most nonsurvivors died within 48 hrs. Eleven patients without additional limitation or withdrawal of care survived to hospital discharge (11/237 [4.6%]). No patient survived a terminal wean.

CONCLUSIONS

There is now an increasing probability that impending death will be acknowledged by a formal terminal care decision. Such decisions may become even more frequent with the dialogue generated by the Patient Self Determination Act and the advent of decisions based on physiologic futility.