ArticlesWithholding and withdrawal of life support in intensive-care units in France: a prospective survey
Introduction
30 years after the advent of intensive care, the uncertain benefits of aggressive and costly life-support treatments for some critically ill patients have raised many ethical and practical questions for physicians working in intensive-care units (ICUs). Reports of clinical studies and guidelines have been published, in the USA especially, to govern and justify the withholding or withdrawal of lifesaving treatments.1, 2, 3, 4, 5, 6, 7, 8, 9, 10 There are no such guidelines in France, where the relationship between patient and physician is limited to a traditional paternalism, based on the principle of beneficence.11 However, societal changes have imposed new rights for the patient to be more informed. So far, only a few clinical studies on withholding or withdrawal of life support, involving a restricted number of patients or only a few participating centres, have been done in France.12, 13, 14
We undertook a large survey of practices in withholding and withdrawal of life-sustaining treatments in French ICUs to assess the frequency of such practices, the therapies withheld or withdrawn, and the processes leading to these decisions.
Section snippets
Participants
220 ICUs from university or general public hospitals registered in the database of the Societé de Réanimation en Langue Française were asked to take part in the study (51 in university hospitals and 169 in general hospitals). Paediatric ICUs and coronary-care units were not involved in this study. 148 (67%) agreed to take part. In each ICU, a volunteer from the medical staff was responsible for collecting the data prospectively. This individual was ideally a senior staff member, with knowledge
Results
Of the 220 ICUs asked to take part in the study, 148 agreed (67%), 49 (22%) declined, and 23 (10%) did not respond to the proposal. 35 (24%) of the 148 units were excluded because they did not complete the questionnaires or because of missing data. Data were fully available for 113 (51%) of 220 units. 29 (26%) of these were in university hospitals and 84 (74%) in general public hospitals. In terms of the number of beds, the participating ICUs represent 49·6% of the total (1148 of 2316). The
Discussion
The main finding of this study was that 53% of the ICU deaths in a large prospective study in France were preceded by a decision to withhold or withdraw life-support therapies. Similar figures have been commonly reported from the USA,1 but rates have rarely been reported from western Europe, especially from Latin countries such as France. Smedira and colleagues1 reported a similar frequency of decisions to withhold or withdraw therapy in 1990 in two ICUs in San Francisco, CA, USA.1 However,
References (27)
- et al.
Abandon ou acharnement thérapeutique en réanimation: évaluation des pratiques médicales
Réan Urg
(1995) - et al.
Association des Réanimateurs de Centre-Ouest. Limitations et arrêts des thérapeutiques actives en réanimation: expériences de dix centres
Réan Urg
(1996) - et al.
Décisions de limitation ou d'engagement thérapeutique maximal dans une unité de réanimation neurochirurgicale
Ann Fr Anesth Réanim
(1997) The clinical management of dying patients receiving mechanical ventilation. A survey of physician practice
Chest
(1994)- et al.
Withholding and withdrawal of life support from the critically ill
N Engl J Med
(1990) - et al.
Process of forgoing life-sustaining treatment in a university hospital: an empirical study
Crit Care Med
(1992) - et al.
Decisions to limit or continue life-sustaining treatment by critical care physicians in the United-States: conflicts between physicians' practices and patients' wishes
Am J Respir Crit Care Med
(1995) - et al.
A national survey of end-of-life care for critically ill patients
Am J Respir Crit Care Med
(1998) Consensus report on the ethics of foregoing life-sustaining treatments in the critically ill
Crit Care Med
(1990)Withholding and withdrawing life-sustaining therapy
Am Rev Respir Dis
(1991)
Attitudes of critical care medicine professionals concerning forgoing life-sustaining treatments
Crit Care Med
Developing guidelines for decision to forego life-prolonging medical treatment
J Med Ethics
Cited by (425)
Withholding and withdrawing therapy in intensive care
2023, Bulletin de l'Academie Nationale de MedecineThe intersection of prognostication and code status in patients with severe brain injury
2022, Journal of Critical CareEvaluation of an aid to the drafting of an advanced care plan
2022, Medecine PalliativeAn Interprofessional Process for the Limitation of Life-Sustaining Treatments at the End of Life in France
2022, Journal of Pain and Symptom Management
Other members listed at emd of paper