End-of-life care and expectations are difficult topics for many families and even some clinicians. Over the past few years, the caregiving emphasis has shifted from an effort to save or prolong someone's life by any means necessary to a more nuanced approach that favors quality of life. Doing so often means removing or avoiding invasive medical interventions such as mechanical ventilation, or breathing tubes, and other procedures such as continuous intravenous medications and dialysis that require frequent monitoring by medical staff.
The expectation by clinicians and patient family members has been that reducing these interventions in order to keep a person more comfortable would likely shorten a patient's life -- a heartbreaking but necessary trade-off in the eye of many patients and their family members.
Now data scientist Daniele Ramazzotti, PhD, and intensive specialist and former Stanford trainee Leo Anthony Celi, MD, from Beth Israel Deaconess Medical Center, have learned that withdrawing invasive medical treatments for dying patients in the intensive care unit doesn't always, in fact, shorten their lifespan.
They published their results recently in PLoS One.
Ramazzotti explained their motivations in an email:
We conducted this study because we have seen that invasive intervention is sometimes administered even to patients with very poor prognosis in an attempt to keep them alive for as long as possible. However, such treatments may sometimes be non-beneficial and instead worsen a patient's last moments. As an example, mechanical ventilation at the end of life deprives patients of their ability to speak with family and friends.
The researchers studied over 6,000 people admitted to the intensive care unit at Beth Israel Deaconess Medical Center in Boston between June 2001 and October 2012 who died within 30 days of their admission. They wanted to know whether there was a downward trend in the use of invasive medical interventions in these patients in response to an end-of-life communication course for ICU residents that was introduced in 2008. If so, they also expected to see a corresponding decrease in the time to death for these patients.
Although the researchers did observe a decrease in the use of mechanical ventilation and other interventions after 2008, particularly for patients deemed to be less severely ill, they didn't see any evidence that this trend caused patients to die more quickly. In fact, the opposite may sometimes be true.
As Celi explained:
We were very surprised by this finding. There is the understanding that the invasive procedures in the ICU are life-saving, and withholding or withdrawing them would lead to immediate death. Families and friends of dying patients who are not ready to say goodbye would therefore opt for these procedures.
But these invasive procedures themselves may hasten death in some. In addition, patients on breathing machines are typically given medications to keep them comfortable, but these medications cloud the mind. Due to the medicalization of death, invasive procedures have become the default option because of unrealistic societal expectations of what medicine can offer.
The researchers caution that the study included patients from only one medical center and that each patient's situation is unique. Invasive interventions can be lifesaving for some less severely ill patients. But for those patients with very poor prognosis, the reduction of these interventions may make them more comfortable without shortening their lifespan.
As Ramazzotti said:
As a clinician approaches a family to begin a discussion about focusing on comfort rather than lifesaving measures, it may help to communicate that withholding or withdrawing intensive therapies may not necessarily hasten or cause the death of their loved one. Our hope is that this knowledge will help in reducing the trauma or guilt that may be involved in these very difficult decisions for the family.
Photo by Alex Proimos