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CAN PRACTICE VARIABILITY SURROUNDING END OF LIFE CARE IN THE ICU BE IMPROVED?

Departments of Anesthesia and Medicine, Dalhousie University, Halifax, Nova Scotia B3H 3A7

OBJECTIVE

To determine the impact of an educational intervention on the variability surrounding end-of-life care in the ICU.

SETTING

Tertiary care ICUs in a teaching hospital.

POPULATION

Patients (PRE: n=97) dying in ICU between July 1996 and June 1997 vs those (POST: n=104) dying between May 1998 and April 1999.

STUDY DESIGN

Before and after comparison.

METHODS

A practice review of end-of-life care was conducted for the period July 1996 to June 1997, issues identified, and initiatives designed to improve end-of-life care implemented. These included introduction of an instrument to standardize the process of withdrawal of life support, an educational campaign regarding appropriate end-of-life care, alteration of the nursing progress notes to require documentation of pain and its management, and a prohibition on the use of open-ended physicians' orders. End-of-life care was surveyed (May 1998 to April 1999) to determine the impact on treatments forgone, drug use, and documentation of the process of the withdrawal of life support.

RESULTS

Apart from a higher percentage of patients with a comorbid neurological condition and a greater proportion of patients treated for trauma in the POST group, the groups were similar in their demographics. There was no difference in the proportion of patients in either group for whom inotropic support, use of ancillary medications, or the provision of nutritional support was discontinued. Fewer patients in the POST group received CPR in the 12 hour interval prior to death (PRE=5; POST=0: p<0.05) but the use of dialysis was similar (PRE=2; POST=3). The number of comfort medications was reduced (PRE:2.0±0.9 vs POST:1.6±0.9; p<0.05). The median dose of morphine (PRE: 32 vs POST: 17 mg; p<0.05) and diazepam (PRE: 20 vs POST: 10 mg; p<0.05) was reduced. Documented involvement of physicians in discussion of the plan to withdraw care was not changed (PRE: 98% vs POST: 96%) but there was improved documented involvement of the clergy in the process (PRE: 8 vs POST: 78 cases; p<0.05).

CONCLUSION

Use of an educational program and changes in documentation of the process of the withdrawal of life support led to a reduction in the variability surrounding end-of-life care.

This Article Full Text (PDF) Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hall, R. I. Articles by Rocker, G. M. Search for Related Content PubMed Articles by Hall, R. I. Articles by Rocker, G. M.