Life-support limitation in the pre-hospital setting

Excerpt

Consider this hypothetical scenario: A man in his late 40s is admitted to your hospital from another centre with what is thought to be an acute exacerbation of interstitial lung disease. The underlying diagnosis during a previous admission to internal medicine was uncertain but might have been adult Still's disease. Lung involvement previously was minimal. After transfer from the referring hospital, he deteriorates over a few days despite high-dose intravenous corticosteroids and is admitted to the ICU, where after some more days his oxygen requirements increase to an FiO₂ of 0.9. The chest radiograph is interpreted as showing a worsening of interstitial disease. There is no other organ failure. The attending physician approaches the family with the news that “nothing further can be done.” A second ICU physician is contacted by telephone to verify the plan to withdraw life support and the man dies. At autopsy he does not have interstitial lung disease, but shows features of some diffuse alveolar damage compatible with ARDS and severe pulmonary congestion as another manifestation of his inflammatory underlying condition. In this case, the underlying diagnosis after a short ICU admission was a lot less certain than it seemed to the ICU attending physician. Would a physician from a different background specialty make a different decision? Would the attending physician or family have made a different decision about life support if the clinical diagnosis had been ARDS or severe community-acquired pneumonia? Many of us have treated patients with severe ARDS who recover after many weeks, but we have to be patient; when we don't know the underlying diagnosis, our patients and their families might reasonably expect us to seek expert advice and to be a lot more cautious about any decisions concerning life support. …