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

Abstract

P Pu ur rp po os se e: : 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.M Me et th ho od ds s: : 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. 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. C Co on nc cl lu us si io on ns s: : 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. Objectif : La plupart des décès qui surviennent dans les unités de soins intensifs (USI) suivent le retrait du maintien de la survie (MS). L'évaluation de cette situation, y compris les perspectives reliées à la peine des membres de la famille, est indispensable pour améliorer les soins palliatifs à l'USI. Méthode : Une étude de cohorte prospective multicentrique de six USI canadiennes d'affiliation universitaire comportait 206 patients de l'USI (séjour de = 48 h) qui ont reçu une ventilation mécanique (VM) avant le retrait du MS. Nous avons noté les modes de retrait du MS, leur séquence et leur évolution et l'usage de médicaments (4 h avant ; 4-8 h et 8-12 h avant la mort). Nous avons demandé à un membre de la famille en particulier d'évaluer le confort du patient et les aspects clés des soins palliatifs.Résultats : La VM a été retirée pour 155/206 (75,2 %) patients ; 97/155 (62,6 %)

Donation after cardiocirculatory death in Canada

“…Different approaches to withdrawal of mechanical ventilation have been cited. 29 WLST methods may include, but are not limited to, 1 or more of the following: 1. Terminal extubation (removal of mechanical ventilation and the artificial airway) 2.…”

Brief review: Practice variation in end of life care in the ICU: implications for patients with severe brain injury

“…9,12,13,16 Physicians also make different choices about comfort medications 1 and how mechanical ventilation is withdrawn. 17 These biases potentially influence the framing of discussions with families, the decisions about CPR and whether to formally withhold or withdraw mechanical ventilation. For patients with brain injury, a decision to withdraw life support in advance of criteria for a neurological declaration of death determines whether or not organ donation is pursued.…”

“…49 Outside of Canada there is a body of evidence to suggest that end of life care in the ICU falls short of these standards, leading to calls for better palliation. 50,51 The situation in Canada appears more encouraging with families reporting that most patients die in comfort in the ICU 17 and that the families themselves feel supported during the dying process. 37 However, inconsistencies in end of life care practices may affect where patients die, how they die, the quality of that death 52,53 and whether or not patients are considered for organ and tissue donation in the ICU.…”

Duration of Withdrawal of Life Support in the Intensive Care Unit and Association with Family Satisfaction

“…Even though critical care clinicians are frequently confronted with these decisions, there is little empirical research that provides evidence about how to proceed practically (24,25). In particular, few studies have addressed the issue of the time sequence of withdrawal of life support in the ICU (14,26,27). Clinicians sometimes decide to withdraw a life-sustaining therapy while continuing other active life-sustaining therapies (24); this partial approach to withdrawing life support may suggest some lack of certainty or consistency in the approach to EOL treatment (14,24).…”