THE CLINICAL MANAGEMENT OF DYING PATIENTS RECEIVING MECHANICAL VENTILATION - A SURVEY OF PHYSICIAN PRACTICE

Objective: Despite mechanical ventilation's widespread use, there is scant literature to guide the management of patients receiving mechanical ventilatory assistance who are forgoing life-sustaining treatment. This survey was conducted to characterize physician treatment of such patients. Design: Surveys were mailed to 513 randomly selected critical care physicians and returned by 308 (60 percent); 273 respondents were involved in ventilator management; all others were excluded. Participants: Forty percent of respondents were internists, 28 percent were surgeons, 16 percent were pediatricians, and 11 percent were anesthesiologists; 85 percent of physicians were board eligible/certified in a critical care subspecialty. Results: Fifteen percent of respondents almost never withdrew ventilators from dying patients forgoing life-sustaining treatment; 37 percent did so less than half the time. Twenty-six percent of physicians believed there was a moral difference between withholding and withdrawing ventilators. Of physicians who withdrew ventilators, 33 percent preferred terminal weaning, 13 percent preferred extubation, and the remainder used both methods. Reasons for preferring extubation included the directness of the action (72 percent), family perceptions (34 percent), and patient comfort (34 percent). Reasons for preferring terminal weaning included patient comfort (65 percent), family perceptions (63 percent), and the belief that terminal weaning was less active (49 percent). Morphine and benzodiazepines were used frequently by 74 percent (morphine) and 53 percent (benzodiazepines) of physicians when withdrawing ventilators; 6 percent used paralytics at least occasionally. Conclusions: There is significant variation in the care of dying patients receiving mechanical ventilatory assistance, with 15 percent of respondents almost never withdrawing ventilators from such patients. Two very different methods of ventilator withdrawal each have advocates, yet rationales of patient comfort and family perceptions are matters of individual experience, absent published studies. The occasional use of paralytics during ventilator withdrawal raises concern about current practice.