NCPA - National Center for Policy Analysis

Who Decides When to Pull the Plug?

October 27, 2003

Mechanical ventilation is the most common form of advanced life support in the intensive care unit (ICU), yet the factors associated with physicians' decisions to withdraw ventilation from critically ill patients in anticipation of death are often unclear.

In an observational study, investigators in ICUs, mostly in North America, tried to determine what influenced the outcomes of these discussions about end-of-life care. They focused on the factors that led physicians to withdraw ventilatory support in anticipation of death.

Conventional wisdom holds that the primary determinants of the withdrawal of mechanical ventilation from critically ill patients are age, the severity of illness, and the presence or absence of organ dysfunction. But this study found otherwise:

  • One of the four factors influencing the decision to withdraw ventilatory support was the patient's reliance on medications to maintain blood pressure.
  • The other three factors involved more subjective judgments by the ICU physicians: their predictions of survival and cognitive function beyond the ICU and their perceptions of the patient's preferences.
  • Thus, physicians influence the decision-making process by virtue of how they forecast the patient's future, and the family influences these decisions by helping physicians to understand the patient's desires.

The researchers note that their results call into question the traditional biomedical model of withdrawal of life support that focuses on the patient's age and physiological determinants such as worsening organ function. While they are encouraged that their findings suggest that the process of withdrawal of life support is attentive to patients' wishes, they are also concerned that when patients' are unable to communicate their preference, neither family members nor physicians may accurately represent their wishes.

Source: Deborah Cook, et al., "Withdrawal of Mechanical Ventilation in Anticipation of Death in the Intensive Care Unit," New England Journal of Medicine, September 18, 2003.


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