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Most critically ill patients are perceived to die in comfort during withdrawal of life support: a Canadian multicentre study

[Les grands malades meurent sans souffrance pendant le retrait du maintien des fonctions vitales : une étude canadienne]

Graeme M. Rocker, DM MHSc FRCPC^*, Daren K. Heyland, MD MSc FRCPC^*,||, Deborah J. Cook, MD MSc FRCPC, Peter M. Dodek, MD MHSc FRCPC, Demetrios J. Kutsogiannis, MD MHS FRCPC^¶ and Christopher J. O’Callaghan, DVM MSC PHD MRCVS^||

^* From the Department of Medicine, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia;
Department of Medicine, Kingston General Hospital, Kingston, Ontario;
Departments of Medicine & Clinical Epidemiology & Biostatistics,McMaster University, Hamilton, Ontario.;
Program in Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St. Paul’s Hospital and University of British Columbia,Vancouver, British Columbia;
^¶ Department of Public Health Sciences and Division of Critical Care Medicine, University of Alberta, Edmonton, Alberta;
^|| Department of Community Health and Epidemiology, Queen’s University, Kingston, Ontario, Canada.

Address correspondence to: Dr. G.M. Rocker, #4457, Halifax Infirmary, 1796 Summer Street, Halifax, Nova Scotia B3H 3A7, Canada. Phone: 902-473-6611; E-mail: gmrocker{at}dal.ca

Purpose: 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 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Results: MV was withdrawn from 155/206 (75.2%) patients; 97/155 (62.6%) died after extubation and 58/155 (37.4%) died with an airway in place.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.

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