title: A five-step protocol for withholding and withdrawing of life support in an emergency department: an observational study.
abstract: OBJECTIVE
  The objective of the study was to describe a five-step protocol for withholding and withdrawing of life support (WH/WDLS) in an emergency department (ED) for terminally ill patients.
  
  
  METHODS
  An observational study was conducted in ED of a general hospital.
  
  
  METHODS
  A total of 98 patients were admitted over a 1-year period.
  
  
  METHODS
  The healthcare team chose a pattern of treatment limitation on the basis of a five-step protocol for every patient, which comprised five groups: group 1: there was no limitation of care, group 2: do not resuscitate order was followed, group 3: administration of therapies without treating an acute organ failure, group 4: active withdrawal of all therapies except mechanical ventilation and group 5: active withdrawal of mechanical ventilation. All the patients received comfort care. The opinions of the patients and their families were collected.
  
  
  RESULTS
  Ninety-eight patients were included in the study (1.5% of admissions). Mean age was 82+/-13 years. An acute organ failure was observed at admission in 80 patients. Severe chronic disease was noted in 93 patients. Among the 98 patients, there were 14 patients in group 2, 65 in group 3, six in group 4 and 13 in group 5. The time interval between admission and WH/WDLS decision was 117+/-77 min and ED stay was 239+/-136 min. The outcome was death in ED (n=21), admission to a medical ward (n=71) or an intensive care unit (n=six). On day 30, 16 patients were still alive.
  
  
  CONCLUSIONS
  This five-step protocol could improve collaboration in the WH/WDLS decision-making process, while facilitating dialogue and transmission of information between staff and families.
authors.affiliation: Emergency Department, General Hospital of Bourg en Bresse, 900 Route de Paris, 01012 Bourg en Bresse, France. nichosed@yahoo.fr
authors.forename: Nicholas
authors.initials: N
authors.lastname: Sedillot
authors.forename: Laurent
authors.initials: L
authors.lastname: Holzapfel
authors.forename: Thierry
authors.initials: T
authors.lastname: Jacquet-Francillon
authors.forename: Nathalie
authors.initials: N
authors.lastname: Tafaro
authors.forename: Ali
authors.initials: A
authors.lastname: Eskandanian
authors.forename: Sarah
authors.initials: S
authors.lastname: Eyraud
authors.forename: Pierre
authors.initials: P
authors.lastname: Metton
authors.forename: Sylvain
authors.initials: S
authors.lastname: Prost
authors.forename: Patrice
authors.initials: P
authors.lastname: Serre
authors.forename: Laure
authors.initials: L
authors.lastname: Souton
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital; D005066:Euthanasia, Passive; D005602:France; D006801:Humans; D008875:Middle Aged; D010166:Palliative Care; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D016414:Resuscitation Orders; D013727:Terminal Care; D028761:Withholding Treatment