title: Simple changes can improve conduct of end-of-life care in the intensive care unit.
abstract: OBJECTIVE
  To describe changes to the conduct of withdrawal of life support (WOLS) in two teaching hospital tertiary care medical surgical intensive care units (ICUs) in a single centre over two distinct time periods.
  
  
  METHODS
  We used a retrospective chart review with a before and after comparison. We assessed aspects of end-of-life care for ICU patients dying after a WOLS before and after we introduced instruments to clarify do not resuscitate (DNR) orders and to standardize the WOLS process, sought family input into the conduct of end-of-life care, and modified physicians' orders regarding use of analgesia and sedation.
  
  
  RESULTS
  One hundred thirty-eight patients died following life support withdrawal in the ICUs between July 1996 and June 1997 (PRE) and 168 patients died after a WOLS between May 1998 and April 1999 (POST). Time from ICU admission to WOLS (mean +/- SD) was shorter in the POST period (191 +/- 260 hr PRE vs 135 +/- 205 hr POST, P = 0.05). Fewer patients in the POST group received cardiopulmonary resuscitation in the 12-hr interval prior to death (PRE = 7; POST = 0: P < 0.05). Fewer comfort medications were used (PRE: 1.7 +/- 1.0 vs POST: 1.4 +/- 1.0; P < 0.05). Median cumulative dose of diazepam (PRE: 20.0 vs POST: 10.0 mg; P < 0.05) decreased. Documented involvement of physicians in WOLS discussions was unchanged but increased for pastoral care (PRE: 10/138 vs POST: 120/168 cases; P < 0.05). The majority of nurses (80%) felt that the DNR and WOLS checklists led to improved process around WOLS.
  
  
  CONCLUSIONS
  Simple changes to the process of WOLS can improve conduct of end-of-life care in the ICU.
authors.affiliation: Department of Anesthesia, Dalhousie University, and the Intensive Care Services, Canada.
authors.forename: Richard I
authors.initials: RI
authors.lastname: Hall
authors.forename: Graeme M
authors.initials: GM
authors.lastname: Rocker
authors.forename: Dawnelda
authors.initials: D
authors.lastname: Murray
mesh_terms: D000368:Aged; D000700:Analgesics / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D016887:Cardiopulmonary Resuscitation; D002423:Cause of Death; D003975:Diazepam / Q000627:therapeutic use; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007362:Intensive Care Units; D008020:Life Support Care; D008297:Male; D008875:Middle Aged; D009726:Nurses / Q000523:psychology; D010166:Palliative Care; D010327:Pastoral Care; D010343:Patient Admission; D010820:Physicians / Q000523:psychology; D016414:Resuscitation Orders; D012189:Retrospective Studies; D028761:Withholding Treatment
chemical_list: D000700:Analgesics; D006993:Hypnotics and Sedatives; D003975:Diazepam