• D A Asch, K Faber-Langendoen, J A Shea, and N A Christakis.
• Veterans Affairs Medical Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia 19104-6218, USA.
• Am. J. Med. 1999 Aug 1; 107 (2): 153-6.

PurposeTo describe the observed sequence of withdrawal of eight different forms of life-sustaining treatment and to determine whether aspects of those treatments determine the order of withdrawal.Subjects And MethodsWe observed 211 consecutive patients dying in four midwestern US hospitals from whom at least one of eight specific life-sustaining treatments was or could have been withdrawn. We used a parametric statistical technique to explain the order of withdrawal based on selected characteristics of the forms of life support, including cost, scarcity, and discomfort.ResultsThe eight forms of life support were withdrawn in a distinct sequence. From earliest to latest, the order was blood products, hemodialysis, vasopressors, mechanical ventilation, total parenteral nutrition, antibiotics, intravenous fluids, and tube feedings (P <0.0001). The sequence was almost identical to that observed in a previous study based on hypothetical scenarios. Forms of life support that were perceived as more artificial, scarce, or expensive were withdrawn earlier.ConclusionThe preference for withdrawing some forms of life-sustaining treatments more than others is associated with intrinsic characteristics of these treatments. Once the decision has been made to forgo life-sustaining treatment, the process remains complex and appears to target many different goals simultaneously.

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