Elsevier

The Lancet

Volume 357, Issue 9249, 6 January 2001, Pages 9-14
The Lancet

Articles
Withholding and withdrawal of life support in intensive-care units in France: a prospective survey

https://doi.org/10.1016/S0140-6736(00)03564-9Get rights and content

Summary

Background

In France, there are no guidelines available on withholding and withdrawal of life-sustaining treatments, and information on the frequency of such decisions is scarce.

Methods

We undertook a prospective 2-month survey in 113, of a total of 220, intensive-care units (ICUs) in France to study the frequency of, and processes leading to, decisions to withhold and withdraw life-sustaining treatments.

Findings

Life-supporting therapies were withheld or withdrawn in 807 (11·0%) of 7309 patients (withholding in 336 [4·6%] and withdrawal in 471 [6·4%], preceded in 358 by withholding). Of 1175 deaths in ICU, 628 (53%) were preceded by a decision to limit life-supporting therapies. Futility and poor expected quality of life were the most frequently cited reasons. Decisions were strongly correlated with the simplified acute physiological score, but an independent centre effect persisted after adjustment for this score. Decisions were mostly taken by all the ICU medical staff, with (54%) or without (34%) the nursing staff; however, a single physician made decisions in 12% of cases. The patient's family was involved in the decision-making process in 44% of cases. The patient's willingness to limit his or her own care was known in only 8% of the cases; only 0·5% of the patients were involved in decisions.

Interpretation

Withholding and withdrawal of life-support therapies are widely practised in French ICUs, despite their prohibition by the French legislation. The lack of an official statement from French scientific bodies may explain several limitations on the various steps of the decision-making process.

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)

  • Attitudes of critical care medicine professionals concerning forgoing life-sustaining treatments

    Crit Care Med

    (1992)
  • Developing guidelines for decision to forego life-prolonging medical treatment

    J Med Ethics

    (1992)
  • Cited by (425)

    • Withholding and withdrawing therapy in intensive care

      2023, Bulletin de l'Academie Nationale de Medecine
    View all citing articles on Scopus

    Other members listed at emd of paper

    View full text