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Simple changes can improve conduct of end-of-life care in the intensive care unit

[Des changements simples peuvent améliorer les soins aux mourants à l’unité des soins intensifs]

Richard I. Hall, MD FRCPC FCCP^*, Graeme M. Rocker, MHSc DM FRCP FRCPC and Dawnelda Murray, RN

^* From the Departments of Anesthesia, and
Medicine, Dalhousie University, and
the Intensive Care Services, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.

Address correspondence to: Dr. Graeme Rocker, Critical Care Program, Queen Elizabeth II Health Sciences Centre, 1796 Summer Street, Room 4457 HI, Halifax, Nova Scotia B3H 3A7, Canada. Phone: 902-473-6611; Fax: 902-473-6202; E-mail: gmrocker{at}dal.ca

Purpose: To describe changes to the conduct of withdrawal of life support (WOLS) in two teaching hospital tertiary care medical surgical intensive care units (ICUs) in a single centre over two distinct time periods.

Methods: We used a retrospective chart review with a before and after comparison. We assessed aspects of end-of-life care for ICU patients dying after a WOLS before and after we introduced instruments to clarify do not resuscitate (DNR) orders and to standardize the WOLS process, sought family input into the conduct of end-of-life care, and modified physicians’ orders regarding use of analgesia and sedation.

Results: One hundred thirty-eight patients died following life support withdrawal in the ICUs between July 1996 and June 1997 (PRE) and 168 patients died after a WOLS between May 1998 and April 1999 (POST). Time from ICU admission to WOLS (mean ± SD) was shorter in the POST period (191 ± 260 hr PRE vs 135 ± 205 hr POST, P = 0.05). Fewer patients in the POST group received cardiopulmonary resuscitation in the 12-hr interval prior to death (PRE = 7; POST = 0: P < 0.05). Fewer comfort medications were used (PRE: 1.7 ± 1.0 vs POST: 1.4 ± 1.0; P < 0.05). Median cumulative dose of diazepam (PRE: 20.0 vs POST: 10.0 mg; P < 0.05) decreased. Documented involvement of physicians in WOLS discussions was unchanged but increased for pastoral care (PRE: 10/138 vs POST: 120/168 cases; P < 0.05). The majority of nurses (80%) felt that the DNR and WOLS checklists led to improved process around WOLS.

Conclusion: Simple changes to the process of WOLS can improve conduct of end-of-life care in the ICU.

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