Abstract
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MV was withdrawn from 155/206 (75.2%) patients; 97/155 (62.6%) died after extubation and 58/155 (37.4%) died with an airway in place.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.
Résumé
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 (15,2 %) patients; 97/155 (62,6 %) sont décédés après l’extubation et 58/155 (37,4 %) avec une intubation en place. Les médicaments les plus utilisés et les doses cumulatives [médiane (valeurs extrêmes)] des quatre heures précédant le décès ont été: la morphine 119/206, 24 mg, (2–450 mg); le midazolam 45/206, 24 mg, (2–380 mg) et le lorazépam 35/206, 4 mg, (1–80 mg). Ces doses étalent similaires pour les trois périodes de temps avant la mort. Des 196 réponses des membres des familles, la majorité Indiquait que les patients semblaient bénéficier d’un confort total (73, 37,2 %), d’un grand confort (48, 24,5 %) ou d’un confort raisonnable (58, 29,6 %). Le temps précédant le décès, l’usage de morphine et la perception des membres de la famille sur le confort du patient ont été similaires pour chacun des types de modification apportée à la VM.
Conclusion
La majorité des patients meurent sans souffrance pendant le retrait du MS selon l’évaluation des membres de leur famille. La perception du confort du patient et l’usage de médicaments pendant les heures qui précèdent la mort ne sont pas associés au mode ou à la séquence du retrait du MS ou à la période de temps avant la mort.
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Partial funding provided by the Canadian Intensive Care Foundation and Queen Elizabeth II Health Sciences Center Research Foundation.
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Rocker, G.M., Heyland, D.K., Cook, D.J. et al. Most critically ill patients are perceived to die in comfort during withdrawal of life support: a Canadian multicentre study. Can J Anesth 51, 623–630 (2004). https://doi.org/10.1007/BF03018407
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DOI: https://doi.org/10.1007/BF03018407