Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers

Crit Care Med. 2006 Aug;34(8):2053-9. doi: 10.1097/01.CCM.0000227654.38708.C1.


Objective: Many intensive care unit (ICU) physicians have withdrawn life-support from a patient who lacked decision-making capacity and a surrogate decision-maker, yet little is known about the decision-making practices for these patients. We sought to determine how often such patients are admitted to the ICU of a metropolitan hospital and how end-of-life decisions are made for them.

Design: Prospective, observational cohort study.

Patients and setting: Consecutive adult patients admitted to the medical ICU of a metropolitan West Coast hospital during a 7-month period in 2003 to 2004.

Measurements: Attending physicians completed a questionnaire about the decision-making process for each patient for whom they considered limiting life-support who lacked decisional capacity and a legally recognized surrogate decision-maker.

Main results: Of the 303 patients admitted during the study period, 49 (16%; 95% confidence interval [CI], 12-21%) lacked decision-making capacity and a surrogate during the entire ICU stay. Compared with all other ICU patients, these patients were more likely to be male (88% vs. 69%; p = .002), white (42% vs. 23%; p = .028), and > or =65 yrs old (29% vs. 13%; p = .007). Physicians considered withholding or withdrawing treatment from 37% (18) of the 49 patients who lacked both decision-making capacity and a surrogate decision-maker. For 56% (10) of these 18 patients, the opinion of another attending physician was obtained; for 33% (6 of 18), the ICU team made the decision independently, and for 11% (2 of 18), the input of the courts or the hospital ethics committee was obtained. Overall, 27% of deaths (13 of 49) during the study period were in incapacitated patients who lacked a surrogate (95% CI, 15-41%).

Conclusions: Sixteen percent of patients admitted to the medical ICU of this hospital lacked both decision-making capacity and a surrogate decision-maker. Decisions to limit life support were generally made by physicians without judicial or institutional review. Further research and debate are needed to develop optimal decision-making strategies for these difficult cases.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Age Distribution
  • Critical Illness
  • Decision Making*
  • Ethics Committees, Clinical
  • Female
  • Humans
  • Informed Consent*
  • Intensive Care Units
  • Length of Stay
  • Male
  • Mental Competency*
  • Middle Aged
  • Practice Patterns, Physicians'
  • Prospective Studies
  • Resuscitation Orders*
  • Sex Distribution
  • Surveys and Questionnaires
  • Third-Party Consent*
  • United States
  • Withholding Treatment*