EOL in incapacitated ICU patients with no surrogates

Some EOL decisions made without ethics consult

Physicians in intensive care settings at times make the decision to withdraw life-supporting care from patients who are incapacitated and have no surrogate decision makers or advance directives.1 But how often does it happen?

According to investigators led by University of California ethicist Douglas D. White, MD, MAS, 5% of all deaths in intensive care units (ICUs) involve patients who lacked surrogates or advance directives, and when physicians considered limiting life support in those patients, they usually did so without institutional or judicial review. White's latest findings are reported in a recent issue of Annals of Internal Medicine.2

White points out that patients without advance directives or surrogates "pose ethical and practical dilemmas in intensive care units." Further complicating such situations, he adds, is the fact that hospital policies, professional society guidelines, and state laws on making end-of-life decisions for those patients vary widely.

White and his colleagues conducted a study that included all adults who were admitted to the medical or medical-surgical ICUs of seven hospitals in a six-month period during 2004 to 2005. The hospitals are in metropolitan areas in California, Oregon, Washington, Pennsylvania, New York, and New Hampshire.

Attending physicians at the hospitals were told they were participating in a study on the processes of care for incapacitated patients without surrogates. If the attendings indicated that withholding or withdrawing life-sustaining treatment had been considered or would have been considered if a surrogate had been available, they completed a questionnaire that detailed the patient's care, decisions that were considered, and decisions that were made.

The study rendered the hospitals, physicians, and patients anonymous to protect patient confidentiality and guard against possible physician liability.

During the study period, 3,011 patients were admitted to ICUs, and the combined mortality rate for all intensive care units was 15% (451 patients). The percentage of ICU deaths that occurred in incapacitated patients without surrogates and advance directives ranged from 0% to 27%, with an overall rate of 5.5% (25 patients).

Physicians reported that in 37 incapacitated patients with no surrogate and no advance directive, they considered or would have considered limiting life support if a surrogate had been available.

In five of the 37 patients, the physicians did not consider limiting life support, but would have if a surrogate had been available. In those 5 patients, the physicians did not involve anyone else in the decision-making process.

In 10 of the 37 patients, physicians consulted other members of the patient's health care team on at least one of the life-sustaining care decisions, but did not involve hospital review committees or other attending physicians and did not seek a review by the courts.

In the other 22 cases, the attending physician sought assistance from another attending, a hospital review committee, or the courts.

White reports that five hospitals had an explicit policy about making decision for patients who were incapacitated and lacking surrogates, and in those hospitals, life support decisions were made for five of 14 patients without conforming to the oversight recommended by the policy.

The study also compared decisions made in the incapacitated patients to hospital policies and guidelines on decision making for incapacitated patients without surrogates published by the American Medical Association (AMA), American College of Physicians (ACP), American Geriatrics Society (AGS), American Thoracic Society, American College of Chest Physicians, and Society for Critical Care Medicine. State laws were researched to find laws that pertained to decisions in those patients.

Decisions made in the majority of the 37 patients did not adhere to the policies of the AMA or the ACP; however, all were consistent with the oversight suggested by the AGS.

"When patients without decision-making capacity lack a surrogate and an advance directive, it is generally not possible to know whether the decisions made are those that the patients would have made themselves," reports White. For that reason, "the process by which the decisions are made assumes greater importance," and the authors urge further research and ethical analysis on how decisions for these patients should be considered.2


  1. White DB, Curtis JR, Lo B, et al. Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers. Crit Care Med 2006; 34:2,053-2,059.
  2. White DB, Curtis JR, Wolf LE, et al. Life support for patients without a surrogate decision maker: Who decides? Ann Intern Med 2007; 147:34-40.


For more information, contact:

  • Douglas B. White, MD, MAS, assistant professor of medicine, University of California/San Francisco Program in Medical Ethics. E-mail: dwhite@medicine.ucsf.edu.