Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit.
OBJECTIVE
The intensive care unit remains a setting where death is common, and a large proportion of these deaths are preceded by withdrawal of life support. We describe a quality improvement project implementing and evaluating a "withdrawal of life support order form" to improve quality of end-of-life care in the intensive care unit.


METHODS
Before-after evaluation.


METHODS
County-owned, university-operated, tertiary, level I trauma center.


METHODS
Subjects were 143 nurses and 61 physicians.


METHODS
We conducted a before-after evaluation of the order form's implementation. The order form has sections on preparations, sedation/analgesia, withdrawal of mechanical ventilation, and the principles of life support withdrawal. To evaluate the form, we surveyed intensive care unit clinicians regarding satisfaction with the form, measured nurse-assessed quality of dying and death with a 14-item survey (scored 0 for worst possible death to 100 for best possible), and performed chart review to assess narcotic and benzodiazepine use and time from ventilator withdrawal to death.


RESULTS
We surveyed 143 nurses and 61 physicians about satisfaction with the form. Among nurses reporting that the form was used (n = 73), most (84%) reported that the order form was helpful and they were most satisfied with the sedation and mechanical ventilation sections. Almost all physicians found the form helpful (95%), and > 70% of physicians found three of the four sections helpful (sedation, mechanical ventilation, and preparations). We obtained quality of dying and death scores for 41 patient deaths before and 76 deaths after the intervention. These scores did not significantly change (mean preintervention score, 78.3; mean postintervention score, 74.2; p = .54) before and after the intervention. Total doses of narcotics and benzodiazepines increased after implementation of the order form in the hour before ventilator withdrawal, the hour after ventilator withdrawal, and the hour before death (p < or = .03). There was no change in the median time from ventilator withdrawal to death (preintervention 37 mins, postintervention 39 mins; p = .49).


CONCLUSIONS
Nurses and physicians found the withdrawal of life support order form helpful. The order form did not improve nurses' assessment of patients' dying experience. Medications for sedation increased during the postorder form period without evidence of significantly hastening death. Although the order form was helpful to clinicians and changed medication delivery, demonstrating clear improvements in quality of dying may require larger sample sizes, more sensitive measures, or more effective interventions.
Treece
Patsy D
PD
Division of Pulmonary and Critical Care, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.
Engelberg
Ruth A
RA
Crowley
Lauren
L
Chan
Jeannie D
JD
Rubenfeld
Gordon D
GD
Steinberg
Kenneth P
KP
Curtis
J Randall
JR
D000368:Aged; D000701:Analgesics, Opioid / Q000627:therapeutic use; D014151:Anti-Anxiety Agents / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D003422:Critical Care / Q000523:psychology / Q000592:standards; D004282:Documentation / Q000592:standards*; D004363:Drug Utilization; D005260:Female; D005568:Forms and Records Control; D006766:Hospitals, County; D006785:Hospitals, University; D006801:Humans; D008020:Life Support Care / Q000523:psychology / Q000592:standards; D008297:Male; D008499:Medical Records / Q000592:standards*; D008505:Medical Staff, Hospital / Q000523:psychology; D008875:Middle Aged; D009730:Nursing Assessment / Q000592:standards; D009741:Nursing Staff, Hospital / Q000523:psychology; D011788:Quality of Life; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000523:psychology / Q000592:standards; D017749:Total Quality Management / Q000458:organization & administration; D014193:Trauma Centers; D014861:Washington; D028761:Withholding Treatment
D000701:Analgesics, Opioid; D014151:Anti-Anxiety Agents