An Observational Study on a Protocol for Withdrawal of Life-Sustaining Measures on Two Non-Academic Intensive Care Units in The Netherlands: Few Signs of Distress, No Suffering?
BACKGROUND
Because anticipation of death is common within the intensive care unit, attention must be paid to the prevention of distressing signs and symptoms, enabling the patient to die peacefully. In the relevant studies on this subject, there has been a lack of focus on measuring determinants of comfort in this population.


OBJECTIVE
To evaluate whether dying without distressing signs after the withdrawal of life-sustaining measures is possible using a newly introduced protocol and to analyze the potential influence of opioids and sedatives on time till death.


METHODS
This was a prospective observational study, in two nonacademic Dutch intensive care units after the introduction of a national protocol for end-of-life care. The study lasted two years and included adult patients in whom mechanical ventilation and/or vasoactive medication was withdrawn. Exclusion criteria included all other causes of death.


RESULTS
During the study period, 450 patients died; of these, 305 patients were eligible, and 241 were included. Ninety percent of patients were well sedated before and after withdrawal. Severe terminal restlessness, death rattle, or stridor was seen in less than 6%. Dosages of opioids and sedatives increased significantly after withdrawal, but did not contribute to a shorter time till death according the regression analysis.


CONCLUSIONS
The end-of-life protocol seems effective in realizing adequate patient comfort. Most patients in whom life-sustaining measures are withdrawn are well sedated and show few signs of distress. Dosages of opioids and sedatives increase significantly during treatment withdrawal but do not contribute to time until death. Dying with a minimum of distressing signs is thus practically possible and ethically feasible.
Department of Intensive Care Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands. Electronic address: j.epker@erasmusmc.nl.
Jelle L
JL
Epker
Department of Intensive Care Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
Jan
J
Bakker
Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
Hester F
HF
Lingsma
Department of Intensive Care Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
Erwin J O
EJ
Kompanje
D000367:Age Factors; D000368:Aged; D002317:Cardiovascular Agents / Q000627:therapeutic use; D003422:Critical Care / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007362:Intensive Care Units; D008297:Male; D009426:Netherlands; D011446:Prospective Studies; D012044:Regression Analysis; D012121:Respiration, Artificial / Q000379:methods; D012720:Severity of Illness Index; D013727:Terminal Care / Q000379:methods*; D013997:Time Factors; D028761:Withholding Treatment
D002317:Cardiovascular Agents; D006993:Hypnotics and Sedatives
Signs of discomfort; intensive care; opioids and sedatives; peak pressure; time till death; withdrawal of life-sustaining measures