Making Decisions about ICU Care When There is No Next of Kin
Abstract & Commentary
By David J. Pierson, MD, Editor, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: In this study of patients admitted to the medical ICU in a metropolitan West Coast hospital, 16% of them lacked decision-making capacity and had no surrogate decision-maker available. Decisions about life-sustaining treatment were mainly made independently by the physicians caring for these patients.
Source: White DB et al, Crit Care Med. 2006;34:2053-2059.
An elderly man is found hypothermic and unresponsive in a bus station, and is brought by paramedics to the nearest hospital. En route he develops pulseless electrical activity and requires cardiopulmonary resuscitation. After stabilization in the emergency department, he is admitted to the medical ICU. Over the next four days, the patient is treated for pneumonia, sepsis and renal insufficiency, is unable to be weaned from the ventilator, and remains unresponsive to painful stimuli. No next of kin can be located despite extensive efforts by the hospital's social workers.
This hypothetical scenario is well-known to critical care clinicians, especially those who work in urban public hospitals. How often similar situations occur, and how physicians managing such patients approach the limitation of life-sustaining treatment in such instances in the absence of surrogate decision makers, were the subjects of this study.
The investigators, from the University of California, San Francisco, and the University of Washington, studied consecutive adult patients admitted to the medical ICU of an unnamed metropolitan hospital on the West Coast during a 7-month period. The target patient population was individuals who lacked decision-making capacity (in the judgment of their ICU physicians) and had no family, legally appointed guardian, advance directive, or health care proxy available and willing to participate in decisions about their care. ICU physicians were contacted daily and asked whether a patient meeting these criteria had been admitted. Attending physicians were queried about "do-not-resuscitate" orders on such patients, and completed a questionnaire about how decisions were made when such orders were enacted or considered. The questionnaire collected information about the attending physicians (demographics, experience, and attitudes) as well as the process of decision-making, and it was pre-tested for validity using structured interviews with attending and resident physicians.
During the study period, 303 patients were admitted to the medical ICU, of whom 72 (24%) lacked decision-making capacity and had no surrogate decision-maker during the initial 48 hours. Patients without surrogates were more likely to be male (88% vs 69%, p = 0.002), white (42% vs 23%, p = 0.028), and at least 65 years old (29% vs 13%, p = 0.007). They were also more likely to have been admitted for acute respiratory failure (49% vs 34%, p = 0.001). Of the patients without surrogates, 24% (17 of 71 with complete data) regained decision-making capacity before a decision-maker could be located. In another 7% (5/71) a surrogate decision-maker was found. The remaining 69% (49/71; 16% of the entire ICU cohort) did not regain decision-making capacity and no surrogate decision-maker was found for them. During the study period, 27% of all deaths (13/49) in the unit involved incapacitated patients lacking surrogate decision-makers. Median length of ICU stay was twice as long in incapacitated patients as in all other patients during the study period (6 vs 3 days, p < 0.0001).
Physicians considered withholding or withdrawing life-sustaining treatment from 18 of the 49 patients (37%) who lacked both decision-making capacity and a surrogate decision-maker. The opinion of another physician was sought in 10 (56%) of these instances. In 6 cases (33%) the ICU team made the decision independently. In 2 instances (11%), the input of the courts or of the hospital's ethics committee was sought.
Physicians cited a poor prognosis for short-term survival as the most common reason for considering an order not to attempt resuscitation in these patients. In 11 of the 18 patients in whom such an order was considered, judgments about future quality of life were stated as factors in the decision-making process. Considerations about the inappropriate use of scarce resources were invoked in only 3 patients, and legal concerns were cited only twice. Life support was ultimately withdrawn in 8 of the 15 patients in whom it was considered.
Commentary
In this study, the first to formally address how often ICU patients lack both medical decision-making capacity and surrogate decision-makers, 16% of all patients admitted to the medical ICU ultimately fell into that category. About a quarter of all ICU deaths during the study period were in such patients. Decision making for these patients was variable but was generally done solely by physicians. A substantial proportion of the patients served by the hospital at which this study took place are homeless or otherwise marginalized in society; it is noteworthy, as pointed out by the authors, that previous work has found physicians to underestimate the wishes of homeless persons for aggressive life-sustaining treatment.1
Repeating this investigation in hospitals serving different patient populations or in different parts of the country would likely produce somewhat different results. However, the fact remains that patients without decision-making capacity or an available surrogate decision-maker comprise a substantial proportion of those in whom decisions about withholding or withdrawing life support need to be made. An earlier study found that one-third of intensivists practicing in the United States acknowledged having discontinued mechanical ventilation in such patients.2 As the authors point out, the individual states either have no laws addressing how decisions about life-sustaining treatment should be made in such patients, or vary in how their existing laws deal with the issue. The problems presented by such patients are thus both difficult and complex. Further study of this issue, more discussion of how it should be managed, and greater availability of resources and guidelines for dealing with patients without decision-making capacity or available surrogates, would surely benefit such patients and those who care for them in the ICU.
References
- Norris WM, et al. Treatment preferences for resuscitation and critical care among homeless persons. Chest. 2005;127:2180-2187.
- Asch DA, et al. Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: Conflicts between physicians' practices and patients' wishes. Am J Respir Crit Care Med. 1995;15(2, pt 1):288-292.
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