Changing patterns of terminal care management in an intensive care unit

Objective: To empirically describe changes in terminal care management behavior over time with the advent of natural death acts and public dialogue and institutional policy regarding terminal care. Design: Retrospective analysis of medical decision-making and outcome was performed in a cohort of 237 intensive care unit (ICU) patients who received a do-not-resuscitate decision. Setting: Medical ICU in a tertiary care center. Patients: The cohort of 237 consecutive patients who received a terminal care decision in the ICU, i.e., a do-not-resuscitate decision with or without additional limitation of care, represented 9.3% of 2,185 patients admitted to the ICU over a 4-yr period. Brain-dead patients were excluded from the cohort. Interventions: Implementation of hospital-wide policies on do-not-resuscitate decisions and discontinuation of life-prolonging procedures in 1986. Measurements and Main Results: A change in frequency and nature of terminal care decisions occurred. By 1988, do-not-resuscitate decisions occurred twice as often as in 1984 (p = .016) compared with ICU deaths. Formal terminal wean decisions, i.e., additional limitation or withdrawal of care, occurred more frequently after 1985 (p = .027). The hospital mortality rate for the do- not-resuscitate cohort was 96.4% (226/237). The diagnosis of cardiac arrest was correlated with subsequent terminal care decisions (p = .0005, r² = .08). Age of >56 yrs was increasingly correlated with probability of a terminal care decision (p < .00001, r² = .05). White women received withdrawal of care most frequently, followed by white men, African American men, and African American women. Outcomes analysis indicated that after a do- not-resuscitate decision, most nonsurvivors died within 48 hrs. Eleven patients without additional limitation or withdrawal of care survived to hospital discharge (11/237 [4.6%]). No patient survived a terminal wean. Conclusions: There is now an increasing probability that impending death will be acknowledged by a formal terminal care decision. Such decisions may become even more frequent with the dialogue generated by the Patient Self Determination Act and the advent of decisions based on physiologic futility.