Withholding and withdrawal of life support are the processes by which various medical interventions either are not given to or are removed from patients with the expectation that they probably will die without such interventions. These processes are possible because technologic advances have allowed life to be supported in the first place. Because life support is often extended to critically ill patients, the question of whether to withhold or withdraw such support comes up frequently in the intensive care unit (ICU). This article examines withholding and withdrawal of life support from an ICU perspective. It begins with a historic review that specifically relates withholding and withdrawal of life support to critically ill patients. We then discuss the evolving concepts of life and death in American society, legal opinions regarding withholding or withdrawing support, the use of advance directives in such patients, medical opinions regarding withholding or withdrawing support, and how such support actually is withheld or withdrawn.
Physicians today consider it their professional duty to prolong life under most circumstances. Although this duty appears to be time honored, it actually is a modern phenomenon. According to Amundsen, the Hippocratic Corpus described the three roles of medicine as relieving suffering, attenuating disease, and refraining from treating hopelessly ill persons, lest physicians be thought of as charlatans. However, the emergence of medicine as a science led physicians to care for the sickest patients in order to understand the pathophysiology of their maladies. Society then became more secular, and patients became convinced that life should be extended. Physicians in turn developed technologies to support life, and such support became a primary obligation of medicine.
Part of this obligation stems from what Fuchs has called the “technological imperative—the desire of the physician to do everything that he has been trained to do regardless of the benefit-cost ratio. ” This imperative is particularly compelling in the ICU, where patients are likely to die without aggressive management. Critically ill patients also tend to suffer from stroke, trauma, postoperative complications, and other unanticipated problems that often have occurred before they have expressed their wishes regarding treatment. Furthermore, the patients often are comatose or unable to communicate because they are intubated and sedated. They therefore cannot participate in medical discussions or dissuade their physicians from supporting them.
Other factors also contribute to the tendency to treat in the ICU. For example, medical responsibility for critically ill patients often is diffuse and divided among subspecialists who manage specific organ systems but may fail to take a global point of view Retrospective reimbursement has made ICU admissions profitable for hospitals, just as fee-for-service and procedure-oriented payment has prompted physicians to manage patients in the ICU. Although relatively few malpractice suits have been brought in the ICU because the patients are quite sick and expected to die, unlike those who are undergoing elective surgical procedures, physicians still practice defensive medicine in this setting, especially when iatrogenic insults have necessitated ICU admission. Finally, because of the heterogeneous nature of critically ill patients, ICU outcome studies have been difficult to perform and have become available only recently.