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  • Many, if not most, patients who die in intensive care units do so during the withholding or withdrawing of life-sustaining therapy and the administering of palliative care.
  • Life-sustaining therapy usually is withheld or withdrawn and palliative care is administered because physicians and patients or their surrogates agree that further restorative care would not be beneficial.
  • Cardiopulmonary resuscitation, mechanical ventilation, and vasoactive drugs are the therapies most commonly withheld or withdrawn.
  • Palliative care involves attention to the physical, emotional, and spiritual needs of patients and their families.
  • Withholding or withdrawing of life-sustaining therapy and administering of palliative care are well supported by ethical pronouncements and case law.

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Withholding or withdrawing of life-sustaining therapy or life support is a process by which various medical interventions either are not given to or are taken away from patients with the expectation that they will die from their underlying illnesses. This process is carried out in many medical settings but is especially common in the ICU, which offers an array of therapies capable of sustaining life. An example of withholding life-sustaining therapy is to not provide mechanical ventilation to a patient with chronic obstructive pulmonary disease (COPD) and acute respiratory failure who probably will die without the ventilator but is thought to be unweanable once mechanical ventilation is begun. An example of withdrawing life-sustaining therapy is the removal of mechanical ventilation from a patient with COPD with the provision that he or she will neither be ventilated again if acute respiratory failure recurs nor receive cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. This second patient is different from a patient with COPD who is being weaned from mechanical ventilation and will be ventilated again or resuscitated if he or she deteriorates during the weaning process.

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Strictly speaking, all patients who die while receiving close medical attention in an ICU or elsewhere do so as a direct result of the withholding or withdrawal of life-sustaining therapy. This is either because a decision has been made not to resuscitate the patient in advance of decompensation or because even vigorous resuscitation will not be provided indefinitely. For example, the second patient described earlier would receive CPR if he or she were to suffer an unexpected cardiopulmonary arrest during weaning, but CPR would be discontinued if it were not of benefit in restoring a viable cardiac rhythm in, say, an hour. The withdrawal of life support in this second patient would be comparable to the withholding of CPR in the first patient but for the fact that deliberate planning was more possible for the first patient before cardiopulmonary arrest. It is this more deliberate form of withholding and withdrawing of life-sustaining therapy from critically ill adults that is focused on in this chapter, in which the ethical, legal, clinical, and practical aspects of limiting care are discussed.

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Note that the only patients who die in the ICU during the withholding or withdrawing of life-sustaining therapy ...

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