title: A four-step protocol for limitation of treatment in terminal care. An observational study in 475 intensive care unit patients.
abstract: OBJECTIVE
  To describe a four-step protocol for withholding and withdrawal of life support (WH/WDLS) in intensive care unit (ICU) terminal patients.
  
  
  METHODS
  Observational study.
  
  
  METHODS
  A 10-bed ICU of a general hospital.
  
  
  METHODS
  Eighty-three patients out of 475 consecutive patients admitted over a 1 year period had WH/WDLS.
  
  
  METHODS
  The healthcare team chose a pattern of treatment limitation on a four-step protocol for every patient every day. There were four alternatives: group 1: no limitation of care; group 2: patient designated do not resuscitate (DNR) and pressors limited to dopamine at a maximum dose of 20 microg/kg per min; others therapies were continued; group 3: active withdrawal of all therapy except comfort care, i.e., the patient continued to receive nursing, sedation/analgesia, hydration and mechanical ventilation with FIO2=0.21 and no positive end-expiratory pressure (PEEP). Sedation was adjusted to Ramsay 3-4. The group 4 was treated the same as group 3 except that minute ventilation was 5 l/min and sedation/analgesia adjusted to Ramsay 6. WH/WDLS was performed only if the full ICU staff and all family members agreed with the procedure. WH/WDLS was documented in the patient's chart.
  
  
  RESULTS
  Withholding and withdrawal of life support was performed in 83 patients (17%): 25 patients in group 2 (15 deaths), 36 patients in group 3 (36 deaths) and 22 patients in group 4 (22 deaths). Finally, 73 patients died after WH/WDLS. ICU stay was 10+/-17 days, time from admission to WH/WDLS was 184+407 h and time from WH/WDLS to death was 64+/-84 h.
  
  
  CONCLUSIONS
  This four-step protocol may promote medical decision making on end-of-life care.
authors.affiliation: Service de réanimation, Centre Hospitalier, Route de Paris, 01012 Bourg en Bresse, France. lholzapfel@ch-bourg01.fr
authors.forename: Laurent
authors.initials: L
authors.lastname: Holzapfel
authors.forename: Guy
authors.initials: G
authors.lastname: Demingeon
authors.forename: Bonnavy
authors.initials: B
authors.lastname: Piralla
authors.forename: Loïc
authors.initials: L
authors.lastname: Biot
authors.forename: Brigitte
authors.initials: B
authors.lastname: Nallet
mesh_terms: D000328:Adult; D000368:Aged; D002985:Clinical Protocols; D005260:Female; D006302:Health Services Research; D006801:Humans; D007362:Intensive Care Units / Q000941:ethics / Q000592:standards*; D008021:Life Support Systems / Q000941:ethics / Q000592:standards; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000458:organization & administration; D013727:Terminal Care / Q000941:ethics / Q000592:standards*; D028761:Withholding Treatment / Q000941:ethics / Q000592:standards*