Background: Health care proxies (HCP), decision-making surrogates and involved family members often struggle with indecision when offered the option of went withdrawal (VW) for a patient who is intubated. A VW is a procedure offered when an intubated patient fails to demonstrate meaningful recovery or the patient is not likely to survive given the extent or burden of underlying medical conditions. An initial palliative consult is usually requested by the primary team at which point the benefits and burdens of all available options, including VW, are discussed in a family meeting setting. Those making the decision on behalf of the patient are often encouraged to choose the course of action that the patient would most likely choose if he/she were able to communicate with the medical staff. The potential for conflict arises when the patient has not assigned a prior HCP to make decisions in such situations, or if the patient had not completed advanced directives, in which case their prior wishes remain unclear. Such conflict may require multiple family meetings with the primary and palliative teams to navigate the interpersonal dynamics and to arrive at a consensus among all involved parties whether or not the patient should undergo VW. We aim to investigate whether having a documented HCP or advanced directives prior to intubation may reduce delays to VW following initial palliative consultation.
Methods: Retrospective chart review of adult patients who underwent VW at our institution between January 2012 and January 2017. Patient demographics, indication for intubatio, primary diagnoses, comorbidities, presence of HCP or advanced directives, as well as dates of intubation, palliative consult and VW were all collected. This study was reviewed and approved by the IRB.
Results: 79 patients reviewed that met inclusion criteria reveal the following: the average number of days between initial palliative consult and initiation of VW was 11.4 days for patients with documented HCP (n=25), and 15.3 days for patients without HCPs (n=54). When stratified for advanced directives (DNR, MOLST, living will) those with advanced directives (n=49) remained on ventilator support for 12.1 days prior to VW, while patients without advanced directives waited 16.7days until VW.
Conclusions: Our data indicate that patients who have an HCP prior to intubation underwent VW on average 3.92 days sooner than those without an HCP, while having advanced directives in place shortened time to VW on average by 4.73 days. Further study with a larger number of patients is required to further confirm the underlying trend that having an HCP and/or advanced directives in place prior to intubation may reduce hospital length of stay by decreasing time to VW.