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

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

Hall RI; Rocker GM; Murray D

Canadian Journal Of Anaesthesia

2004

Female; Humans; Male; Attitude of Health Personnel; Aged; Middle Aged; Resuscitation Orders; Intervention Studies; Patient Admission; Pastoral Care; retrospective studies; cause of death; DNAR; cardiopulmonary resuscitation; Intensive Care Units; Life Support Care; Palliative Care; Withholding Treatment; Analgesics/tu [Therapeutic Use]; Diazepam/tu [Therapeutic Use]; DNAR Outcomes; Hypnotics and Sedatives/tu [Therapeutic Use]; Nurses/px [Psychology]; Physicians/px [Psychology]

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.

2004

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