A multi-institutional study of care given to patients dying in hospitals. Ethical and practice implications.

BACKGROUND: Relatively little attention has been paid to how physicians care for dying patients once an initial decision to forgo life-sustaining treatment is made.
OBJECTIVES: To describe characteristics of patients forgoing treatment, determine the range and sequential process of forgoing treatment, and suggest ethical and practice implications.
METHODS: Charts of 75 consecutive patients dying at each of 4 hospitals were reviewed for this case series. Two hundred ninety-one (98%) of 297 charts were available for review; 274 patients died in acute care beds and are included in this study. Data collected included patients' diagnoses, mental statuses, lengths of stay, timing of the first decision to forgo treatment, and range and sequence of interventions forgone. MAIN OUTCOME MEASURES: Proportion forgoing life-sustaining treatment, number of interventions forgone and decision times per patient, and ranked order of treatment withdrawal.
RESULTS: Two hundred twenty-nine (84%) of 274 patients who died had some intervention forgone before death. Only 35% of patients forgoing life-sustaining treatment were able to participate in decision making. On average, 3.8 interventions were forgone per patient. Resuscitation and/or intubation were generally the first measures withheld; once a patient required ventilatory support, withdrawing ventilatory support was a late decision.
CONCLUSIONS: The majority of patients dying at these institutions did so after decisions to limit treatment, but few patients were able to participate in these decisions. Forgoing life-sustaining treatment generally occurred in a sequential manner over several days; the rationale for this stepwise retreat is not, however, clinically or ethically obvious.