title: Most critically ill patients are perceived to die in comfort during withdrawal of life support: a Canadian multicentre study.
abstract: OBJECTIVE
  Most deaths in intensive care units (ICUs) follow a withdrawal of life support (LS). Evaluation of this process including the related perspectives of grieving family members is integral to improvement of palliation in the ICU.
  
  
  METHODS
  A prospective, multicentre, cohort study in six Canadian university-affiliated ICUs included 206 ICU patients (length of stay >or=48 hr) who received mechanical ventilation (MV) before LS withdrawal. We recorded modes, sequence and time course of LS withdrawal and drug usage (4 hr before; 4-8 hr and 8-12 hr before death). We asked a specified family member to assess patient comfort and key aspects of end-of life care.
  
  
  RESULTS
  MV was withdrawn from 155/206 (75.2%) patients; 97/155 (62.6%) died after extubation and 58/155 (37.4%) died with an airway in place. The most frequently used drugs and the cumulative doses [median (range)] in the four hours before death were: morphine 119/206, 24 mg, (2-450 mg); midazolam 45/206, 24 mg, (2-380 mg); and lorazepam 35/206, 4 mg, (1-80 mg). These doses did not differ among the three time periods before death. Of 196 responses from family members most indicated that patients were perceived to be either totally (73, 37.2%), very (48, 24.5%), or mostly comfortable (58, 29.6%). Times to death, morphine use and family members' perceptions of comfort were similar for each type of change to MV.
  
  
  CONCLUSIONS
  Most patients were perceived by family members to die in comfort during a withdrawal of LS. Perceptions of patient comfort and drug use in the hours before death were not associated with the mode or sequence of withdrawal of LS, or the time to death.
authors.affiliation: Department of Medicine, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada. gmrocker@dal.ca
authors.forename: Graeme M
authors.initials: GM
authors.lastname: Rocker
authors.forename: Daren K
authors.initials: DK
authors.lastname: Heyland
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Cook
authors.forename: Peter M
authors.initials: PM
authors.lastname: Dodek
authors.forename: Demetrios J
authors.initials: DJ
authors.lastname: Kutsogiannis
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: O'Callaghan
mesh_terms: D000701:Analgesics, Opioid / Q000627:therapeutic use; D001293:Attitude to Death; D002170:Canada; D015331:Cohort Studies; D016638:Critical Illness; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007362:Intensive Care Units; D016018:Least-Squares Analysis; D007902:Length of Stay; D008020:Life Support Care; D008140:Lorazepam / Q000627:therapeutic use; D008874:Midazolam / Q000627:therapeutic use; D009020:Morphine / Q000627:therapeutic use; D010166:Palliative Care; D010549:Personal Satisfaction; D011446:Prospective Studies; D012121:Respiration, Artificial; D013997:Time Factors; D028761:Withholding Treatment
chemical_list: D000701:Analgesics, Opioid; D006993:Hypnotics and Sedatives; D009020:Morphine; D008140:Lorazepam; D008874:Midazolam