Achieving consensus on withdrawing or withholding care for critically ill patients.

OBJECTIVE: To examine the decision-making process to withhold or stop life support. DESIGN: Survey. SETTING: Medical intensive care unit of a tertiary care center. PARTICIPANTS: Physicians and families of 15 critically ill patients; in seven cases patients also participated. MEASUREMENTS: Meetings between physicians and family members concerning a decision to withhold or stop treatment of a critically ill family member were tape-recorded. Transcriptions of the meetings were analyzed for 1) process: how the physician introduced the need for a decision, framed the likely outcomes of options, and closed on a decision; 2) what decision was made; and 3) the outcome; died, discharged home, or discharged to another institution. RESULTS: The concept of "patient's wishes" was a central orientation point for the negotiation of consensus regarding withholding or withdrawing therapy even when the patient was not a participant. Physicians tended to provide a direct and unambiguous introduction, give equal weights to options during decision framing, but narrow the options during decision closure to correspond to their judgments. Not every decision was consistent with the physician's judgment. CONCLUSIONS: Decision making to withhold or withdraw life-support therapy from critically ill persons involves complex, difficult processes. Successful management of the tension among life extension, quality of life, patient autonomy, and social justice requires better understanding of these processes.