Intensive Care Med (2004) 30:2216–2221

DOI 10.1007/s00134-004-2475-2 ORIGINAL

Philippe Le Conte
Denis Baron
Withholding and withdrawing life-support
David Trewick therapy in an Emergency Department:
Marie Dominique Touz

C
line Longo prospective survey
Irshaad Vial
Danielle Yatim
Gille Potel

Received: 30 March 2004
Accepted: 15 September 2004
Published online: 29 October 2004

Springer-Verlag 2004
An editorial regarding this article can be
found in the same issue (http://dx.doi.org/
10.1007/s00134-004-2476-1)
P. Le Conte ()) · D. Baron · D. Trewick ·
M. D. Touz · C. Longo · I. Vial ·
D. Yatim · G. Potel
Service d’Accueil et d’Urgences,
Centre Hospitalier Universitaire,
44093 Nantes, France
e-mail: philippe.leconte@chu-nantes.fr
Tel.: +33-2-40083934
Fax: +33-2-40084654
Abstract Objectives: Few studies
have focused on decisions to with-
draw or withhold life-support thera-
pies in the emergency department.
Our objectives were to identify clin-
ical situations where life-support was
withheld or withdrawn, the criteria
used by physicians to justify their
decisions, the modalities necessary to
implement these decisions, patient
disposition, and outcome. Design and
setting: Prospective unicenter survey
in an Emergency Department of a
tertiary care teaching hospital. Pa-
tients: All non-trauma patients
(n=119) for whom a decision to
withhold or withdraw life-sustaining
treatments was taken between Jan-
uary and September 1998. Main out-
come measures: Choice of criteria
justifying the decision to withhold or
withdraw life-sustaining treatments,
time interval from ED admission to
the decision; type of decision imple-
mented, outcome. Results: Fourteen
thousand eight hundred and seventy-
five non-trauma patients were ad-
mitted during the study period, 119
were included, mean age
75€13 years. Resuscitation proce-
dures were instituted for 96 (80%)
patients before a subsequent decision
was taken. Physicians chose on av-
erage 6€2 items to justify their deci-
sion; the principal acute medical
disorder and futility of care were the
two criteria most often used. Median
time interval to reach the decision
was 187 min. Withdrawal involved
37% of patients and withholding 63%
of patients. The family was involved
in the decision-making process in
72% of patients. The median time
interval from the decision to death
was 16 h (5 min to 140 days).
Conclusion: Withdrawing and with-
holding life-support therapy involved
elderly patients with underlying
chronic cardiopulmonary disease or
metastatic cancer or patients with
acute non-treatable illness.

Introduction care medicine. A multicenter survey found that 77% of

A growing number of patients die each year in the
Emergency Department (ED) [1]. These deaths are often
preceded by decisions to withhold or withdraw life-sus-
taining treatments but few studies have focused on deci-
sions to limit life-support in the ED. One such study,
conducted in France, found that 0.19% of patients visiting
the ED died and that a decision to withhold or withdraw
life-sustaining treatments was taken for 53% of them [2].
These decisions have been more widely studied in critical
deaths in US Critical Care Units were associated with
such a decision [3]. The LATAREA study [4] found that
53% of deaths in French Intensive Care Units were pre-
ceded by a similar decision. The ED is a unique setting.
Indeed, physicians often lack crucial data concerning the
previous state of health and autonomy. The absence of an
ongoing long-term relationship with the patient and the
lack of time make a decision to limit life-support partic-
ularly difficult. In the absence of complete information
concerning the patient, the emergency physician’s actions

must always be aimed at sustaining vital functions. Very
few data are available in the literature on this type of
decision in emergency departments, thus we conducted
this study. The goals of this investigation were: to identify
clinical situations where life-support therapies were
withheld or withdrawn, criteria used by physicians to
justify their decisions, modalities necessary to implement
these decisions, patient’s disposition, and outcome.
Patients and methods
Study design
It was a prospective unicenter survey.
Setting
Department of emergency medicine of an inner-city tertiary care
teaching hospital.
Selection of participants
All non-trauma patients admitted to the ED for whom a decision to
withhold or withdraw life-sustaining treatments was taken, by the
attending physician, were included prospectively over a period of
250 days (January 1998 to September 1998). At this time, there was
no written protocol concerning end of life care.
All patients were adults over the age of 15 years and 3 months,
admitted for a non-traumatic aetiology. Only senior staff members
who belonged to the ED could include patients. Each physician
completed a data collection form for every patient for whom a
decision to withhold or withdraw life-sustaining treatments was
taken. All patients continued to receive primary and palliative care
including nursing, oxygen, hydration, and analgesia with or without
sedation as required.
Methods
Withdrawal was defined as a discontinuation of treatments that had
previously been implemented, and withholding was defined as a
predetermined decision not to implement therapies that would
otherwise be deemed necessary because they were considered to be
unable to modify the outcome in these particular instances.
Once the patient was stabilized the medical team could search
for all the objective data (previous state of health, autonomy, un-
derlying chronic disease). This information was then used in
combination with the clinical, biological, and radiological aspects
of the acute presenting illness to make an informed decision con-
cerning the medical benefits of continued treatment. The decision
was not taken unless all information was collected and verified. The
family was involved as often as possible, as was the general
practitioner and, when required, the organ specialist was also
consulted. The decision always followed practice guidelines.
Definition of resuscitation procedures
Resuscitation procedures were defined as follows:
– Endotracheal intubation
– Mechanical ventilation
2217
– IV fluid expansion or massive transfusion (more than two red
cells suspensions)
– Infusion of vasopressors
– Cardiopulmonary resuscitation (in the event of cardiac arrest)
– Renal replacement therapy
– Urgent surgery
– Transfer to an intensive-care unit.
Predefined criteria
The attending physician had to chose one or more of the 17 pre-
defined criteria to justify his or her decision to withhold or with-
draw life-sustaining treatments. The criteria used were as follows:
– Principal acute presenting medical disorder
– Expected irreversibility of acute disorder in the first 24 h
– Underlying disease expected to be fatal in a delay of less than
1 year (McCabe 2)
– Absence of improvement following a period of active treatment
– Severity of illness (Knauss’s classification [5], Organ System
Failure, McCabe’s classification [6], SAPS [7])
– Contraindication to organ donation
– Level of care considered to be maximal
– Previous vegetative state
– Underlying chronic debilitating disease
– Recovery but expected quality of life unacceptably poor
– Age
– Choice of patient
– Family request
Methods of measurement
The following information were also recorded:
1. The time interval from ED admission to the decision to with-
hold or withdraw life-sustaining treatments.
2. The type of initial decision implemented: withholding or
withdrawing life-sustaining treatments.
3. Patient outcome:
– Admission to a hospital ward.
– Time interval between admission to ED and death.
The capacity of each patient to be involved in the decision-
making process was also recorded.
Data collection and processing
Data were collected on a data sheet by the investigators then
computerized on Access (Microsoft, WA)
Statistical analysis
Data was processed using Statview software. A variance analysis
followed by Scheffe’s test was used for quantitative data. Quali-
tative data were compared using a c2 test. P<0.05 was considered to
be significant.
2218

Results disease. This chronic condition was unstable and was the
principal acute presenting medical disorder for 67 patients
Description of the population (56%). Eighty-six patients (73%) were judged to be un-
able to enter the decision-making process: 59 (49.5%) had
A total of 119 non-trauma patients were included. This an acute alteration of their mental status, 19 (16%) a
represented 0.8% of all non-trauma patients admitted to vegetative state and eight were sedated (6.7%).
the ED over the same period. There were 55 (46.2%) men The mean SAPS was 14€4 (5–26), 17 patients had an
and 64 (53.8%) women. The mean age was 75€13 years organ system failure score greater than 3. McCabe’s
(median 79 years, range 27–98 years). Resuscitation classification was as follows: 29 (24.3%) patients were
procedures as described in the section patients and class 0 (absence of underlying disease or underlying
methods were instituted for 96 (80%) patients before a disease not affecting the vital prognosis), 42 (35.3%) were
subsequent decision to withhold or withdraw life-sus- class 1 (underlying disease fatal in a delay of up to
taining therapy (Table 1). For 20% of the patients, it was 5 years), 48 (40.3%) class 2 (underlying disease fatal in a
decided not to start immediately life-support therapy be- delay of up to 1 year). Fifty (42%) patients were Knauss
cause such therapy was not warranted on admission. class A or B, 32 (26.9%) class C and 32 (26.9%) class D.
During follow-up these patients then deteriorated and Data were lacking for five patients (4.2%).
would theoretically have required life support. The deci-
sion to withhold life-support therapy was then taken at
this stage. The most frequent acute presenting medical Decision to withhold
disorders were neurological or cardiovascular (Table 2). or withdraw life-sustaining treatments
Ninety two patients (77%) had an underlying chronic
Physicians chose on average 6€2 items (range 2–10) out
of the 17 predefined criteria to justify their decisions to
Table 1 Life sustaining treatments implemented before a decision withhold or withdraw life-sustaining treatments (Table 3).
of withholding or withdrawing life-support therapy.
The principal acute presenting medical disorder, the ex-
n Percentage pected irreversibility of the acute disorder in the first 24 h,
Intubation 36 30.2 and the level of care considered to be at its maximum
Mechanical ventilation 28 23.5 were the three criteria most often used. One of the pre-
Other techniquesa 32 27 defined criteria the physician had to chose from was
None 23 19.3 “expected quality of life unacceptably poor”. Although
a
Other techniques included IV fluid expansion or massive trans- used 46 times it was never chosen alone but always in
fusion, infusion of vasopressors, and cardiopulmonary resuscitation association with at least one other criteria. Only seven
competent patients chose themselves to withhold life
support therapy.
Table 2 Principal acute presenting medical disorder in 119 patients The decision was discussed by medical and nursing
for whom a decision of withdrawing or withholding of life-support
therapy was taken. staff for 47 (39%) patients, by medical staff alone for 37
(31%) patients, and taken by a single physician for 35
Principal acute disorder n Percentage (29%) patients.
Neurological 45 38 The family was not available for 11 (9%) patients and
Cardiovascular 28 23.5 was not involved in the decision-making process for 22
Respiratory 20 17 (19%) patients. For the remaining 86 patients family
Digestive 16 13.5
Cancer 17 14 members were involved in the decision taking. The ex-
change with the family always took place in person and

Table 3 Criteria used in 119 Criteria used n Percentage

patients for whom a decision of
withdrawing or withholding of Principal acute medical disorder 99 83
life-support therapy was taken. Irreversibility of acute disorder in the first 24 h 72 60
Level of care considered to be maximal 70 59
Severity of illness using scoring systems 48 40
Vegetative state 48 40
Recovery but expected quality of life unacceptably poor 46 39
Underlying disease expected to be fatal in the following 6 months 44 37
Choice of patient 10 8
Age 29 24
Absence of improvement following a period of active treatment 29 24
Underlying chronic debilitating disease 26 22

never over the telephone. The family adhered to the
medical decision for 81 patients (68%) and asked for
active euthanasia for five patients (4%).The decision to
withhold or withdraw life-sustaining treatments was
written in the medical file 117 (98%) times and always
figured in the nursing charts.
The mean time interval from admission to reaching the
decision was 697 min€1,003 (median 187 min, range
5 min–83 h). For 35% of patients, the decision was taken
only after an initial period of 4 h. This delay represented
either a ‘time-limited trial’ designed to assess the efficacy
of resuscitation procedures which had already been ini-
tiated (20% of patients) or was the time needed for re-
covering sufficient data to make an informed decision
(15% of patients). There was no relation between the time
interval to reach the decision and the value of the SAPS
(r=0.23, P=0.36), Glasgow Score (r=0.31, P=0.24),
mental status (r=0.28, P=0.24), number of organ failures
(r=0.35, P=0.79) or Knaus’s class (r=0.29, P=0.7). There
was, however, an inverse relation between the time in-
terval and McCabe’s score (r=0.62, P=0.02).
The type of decision implemented
Withdrawal involved 44 (37%) patients and withholding
75 (63%) patients.
Patient outcome
Eighty-three point nine percent of patients stayed in the
ED or in the Observation Unit of the Emergency De-
partment, 6.2% were admitted to the unit that usually took
care of them, 3.7% were admitted to a medical ward, and
6.2% were discharged from hospital. One month after the
decision to withhold or withdraw life-sustaining treat-
ments, 4% of patients were still alive. The distribution of
time intervals (time between decisions to limit life-sus-
taining treatments and death) was non-parametric, there-
fore mean and standard deviations were not exposed. The
median was 16 h (5 min–140 days). There were no im-
portant differences between the time intervals for with-
holding or withdrawing life-support. Eighty-four point
two percent of patients died in the ED, 7.9% in a medical
ward, and 7.9% in another place. At the present time, 17%
of deaths in our institution occur in the ED.
Discussion
The decision to withhold or withdraw life-sustaining
treatments concerned 0.8% of all non-trauma patients
admitted to our ED; thus, such a decision is taken almost
every day. Indeed, the growing population of elderly
patients, many of whom have multiple chronic debilitat-
2219
ing diseases, makes it more difficult to die at home. We
found that 77% of patients had an underlying chronic
disease, and 53% of patients had severe functional dis-
ability. Wrenn found similar findings concerning US pa-
tients with do-not-resuscitate orders in an inner-city
teaching hospital ED [8]. Another French study found that
35% of patients dying in ED had a terminal disease [9].
However, this fact is probably a French particularity and
cannot be extrapolated to other European countries where
practices might be quite different, depending on different
legislation and general national attitude.
Our patients were less severely ill than those in the
LATAREA study group which was performed in critical
care units [4]. Our population was closer to that of the
PROTOCETIC study [10] which included a high pro-
portion of elderly patients, with underlying chronic car-
diopulmonary disease or metastatic cancer and who were
not admitted to intensive care.
The expected quality of life is a highly subjective
notion and should not be used on its own [11]. In our
series it mainly applied to patients who no longer had an
interaction with their environments (post-anoxic coma,
massive cerebral haemorrhage).
Nursing staff was implicated only in 39% of decisions
(54% in the LATAREA study). The French Society of
Intensive Care (Socit de Ranimation de Langue
Franaise) and the French Society of Emergency Medi-
cine (Socit Francophone de Mdecine d’Urgence) have
since issued guidelines emphasizing the need for collegial
decision-taking and insists particularly on the involve-
ment of nurses [12, 13]. Twenty-nine percent of decisions
were taken by a single physician, this fact is an obvious
ethical limitation.
The family was involved in the decision-making pro-
cess in 73% of cases but was not available for 9% of
patients. This can be compared to the 57% of family in-
volvement in the LATAREA study and the 89% in-
volvement in Wrenn’s study [8]. The relatively low
family involvement in France can be explained by cul-
tural differences and in particular the principal of paternal
beneficence which was at the centre of the doctor to pa-
tient relationship. This principal is now different since the
introduction of a new law in March 2002 on the rights of
patients. In the US a do-not-resuscitate order should be
initiated by the patient himself (life testament), by a
family member or a legal representative [14]. However,
Wrenn found that 65% of decisions were in fact initiated
by the ED physician and then endorsed by the family [8].
We found that family members always agreed with the
decision to withhold or withdraw life-sustaining treat-
ments. In 4% of cases the family asked for the adminis-
tration of lethal drugs which was refused and, after
counselling, they agreed to palliative care. Such care was
organized with the help of the hospital palliative care
team.
2220

The type of decision implemented (withdrawing or
withholding) cannot be compared to the literature because
the only other article dealing with the limitation of life-
support in ED gave no details of the type of decision
taken [8]. The LATAREA study group on patients in ICU
found similar results, the decisions to withhold being
more frequent than the decision to withdraw. Even though
both decisions are morally equivalent, withdrawal is often
considered emotionally harder to assume by medical staff
and nurses. This attitude is defended by Iserson who
considers that a moral difference exists between with-
holding and withdrawal of treatments in special settings
such as EDs [15].
We found that most patients (83%) stayed in the ED
and in the Observation unit of the ED, whereas 62% of
patients in Wrenn’s study were subsequently admitted to
another unit. This maybe a local peculiarity as only 23%
of patients with chronic diseases were hospitalised in the
unit that usually cared for them. No patient was admitted
to intensive care because none meet priority 1 or 2 of the
Prioritisation Model for ICU admission guidelines [16].
The extent of delay between death and the decision
(5 min–140 days) with a median of 16 h tends to reflect
the diversity of situations encountered in ED. Our study
was monocentric and therefore has one major drawback in
that it does not necessarily represent the practice of other
ED physicians in France or in the European Union.
However, the case-mix referred to French ED is relatively
homogenous and it is therefore conceivable that the sit-
uation encountered in these departments and probably in
foreign Emergency Departments is much the same as are
own.
The main finding of this study is that decisions to limit
life-sustaining treatments are relatively frequent in an
emergency department setting. This study raises a number
of ethical issues namely the poor participation of the
patient in the decision-making process as well as the lack
of involvement of the nursing staff.
Official guidelines concerning decisions to limit life-
sustaining treatments in emergency departments have
been recently released by the French Society of Emer-
gency Medicine (SFMU) [13]. Thus physicians can apply
these recommendations and those upheld by the French
and Anglo-American Societies of Critical Care Medicine.
It should be emphasised that only treatment and not care
is withheld or withdrawn, objectives being reoriented to
favour the comfort of patient and relatives. Unless there is
complete agreement between the decision-makers or if
data concerning the patient is lacking the decision must be
postponed.
It should become standard practice for each ED to
have a standardised form on which decisions to withhold
or withdraw life-sustaining treatments can be written and
inserted into the medical file.
In retrospect, this study could have been improved if
its design was multicentric. With this in mind we have
obtained a national grant to launch a multicentric study
which should begin in the summer of 2004 and is de-
signed to explore the epidemiology of deaths in 70
emergency departments throughout France. This study
will especially focus on decisions to limit or to withdraw
life support therapies.
Conclusion
In summary, withdrawing and withholding life-support
therapy concerned elderly patients with underlying
chronic cardiopulmonary disease or metastatic cancer or
patients with acute non-treatable illness. Emergency
physicians are under no ethical obligation to provide or to
maintain treatments they judge to be of no benefit for the
patient. Decisions to withhold or withdraw life-sustaining
treatments are often difficult to take in an ED setting but
are undeniably an integrated part of medical activity.

References
1. Stussman BJ (1997) National hospital
ambulatory medical care survey: 1995
emergency department summary. Ad-
vance data from vital and health statis-
tics; no. 285. National Center for Health
Statistics, Hyattsville, Maryland, USA
2. Roupie E (1999) La mort aux urgences:
enquÞte prospective prliminaire. In:
Actualit en ranimation et urgences.
Elsevier, pp. 281–289
3. Prendergast TJ, Claessens MT, Luce JM
(1998) A national survey of end-of-life
care for critically ill patients. Am J
Respir Crit Care Med 158:1163–1167
4. Ferrand E, Robert R, Ingrand P for the
French LATAREA group (2001) With-
holding and withdrawal of life-support
in intensive care units in France: a
prospective survey. Lancet 357:9–14
5. Knauss WA, Zimmerman JE, Wagner
DP (1981) APACHE: acute physiology
and chronic health evaluation: a physi-
ology based classification system. Crit
Care Med 8:591–597
6. McCabe WR, Jackson GG (1962) Gram
negative bacteremia. Arch Intern Med
110:83–91
7. Le Gall JR, Loirat P, Alperovitch A
(1984) A simplified acute physiology
score for ICU patients. Crit Care Med
12:975–977
8. Wrenn K, Brody SL (1992) Do-not-
rescucitate orders in the emergency
department. Am J med 92:129–133
9. Tardy B, Venet C, Zeni F, Berthet O,
Viallon A, Lemaire F, Bertrand JC
(2002) Death of terminally ill patients
on a stretcher in the emergency de-
partment: a French specialty? Intens
Care Med 28:1625–1628

10. Azoulay E, Pochard F, Chevret S,
Vinsonneau C, Garrouste M, Cohen Y,
Thuong M, Paugam C, Apperre C, De
Cagny B, Brun F, Bornstain C, Parrot
A, Thamion F, Lacherade JC, Bouffard
Y, Le Gall JR, Herve C, Grassin M,
Zittoun R, Schlemmer B, Dhainaut JF,
PROTOCETIC Group (2001) Compli-
ance with triage to intensive care rec-
ommendations. Crit Care Med
292:132–136
11. Marco CA, Larkin GL, Moskop JC,
Derse AR (2000) Determination of
“futility” in emergency medicine. Ann
Emerg Med 35:604–612
12. Socit de Ranimation de Langue
Franaise (2002) Les limitations et arrÞt
de thrapeutique (s) active (s) en ran-
imation adulte. Ranimation 11:242–
249
13. Socit Francophone de Mdecine
d’Urgence (2003) Ethique et urgences
Rflexions et recommandations de la
Socit Francophone de Mdecine
d’Urgence. JEUR 16:106–120
2221
14. American College of Emergency
Physicians (1999) Code of Ethics for
Emergency physicians. Available at
http://www.acep.org/1,1118,0.html.
Accessed 28 March 2004
15. Iserson KV (1996) Withholding and
withdrawing medical treatment: an
emergency medicine perspective. Ann
Emerg Med 28:51–54
16. Task force of the American College of
Critical Care Medicine (1999) Society
of Critical Care Medicine Guidelines
for intensive care admission, discharge
and triage. Crit Care Med 27:633–638