Private attending physician status and the withdrawal of life-sustaining interventions in a medical intensive care unit population.

Abstract

To assess the influence of private attending physician status on the withdrawal of life-sustaining interventions among patients dying within a medical intensive care unit (ICU). Retrospective cohort analysis. An academic tertiary care center. One hundred fifty-nine consecutive patient deaths occurring in the medical ICU during a 12-month period. None. Withdrawal of life-sustaining interventions (i.e., mechanical ventilation, dialysis, and/or vasopressors), duration of mechanical ventilation, length of intensive care unit stay, medical care costs, and patient charges were recorded. Life sustaining interventions were actively withdrawn from 69 (43.4%) patients prior to death. Patients without a private attending physician were significantly more likely to undergo the withdrawal of life-sustaining interventions compared with patients having a private attending physician (odds ratio = 2.5; 95% confidence interval = 1.8, 3.6, respectively; p = .005). A correlation was found between the possession of private health insurance and private attending physician status (r2 = .39, p < .001). Multiple logistic regression analysis was subsequently used to control for demographic factors and severity of illness. Three independent predictors for the withdrawal of life-sustaining interventions were identified in this patient cohort (p < .05) having a planned therapeutic trial of life-sustaining interventions outlined in the medical record (adjusted odds ratio 9.4; 95% confidence interval = 5.6 to 15.6; p < .001); lack of a private attending physician (adjusted odds ratio = 4.4; 95% confidence interval = 2.9 to 6.5; p < .001); and the presence of clearly defined advance directives regarding patient preferences for medical care (adjusted odds ratio = 3.6; 95% confidence interval = 2.3 to 5.7; p. = .005). Patients with private attending physicians had significantly greater medical care costs and medical care charges compared with patients without a private attending physician. Among patients dying within a medical ICU, those patients without a private attending physician are more likely to undergo the active withdrawal of life-sustaining interventions.