Simple changes can improve conduct of end-of-life care in the intensive care unit.
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.
Hall
Richard I
RI
Department of Anesthesia, Dalhousie University, and the Intensive Care Services, Canada.
Rocker
Graeme M
GM
Murray
Dawnelda
D
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
D000700:Analgesics; D006993:Hypnotics and Sedatives; D003975:Diazepam