Standardizing withdrawal of life support

How a QI process can help patients cope

When a dedicated nurse and a quality improvement consultant come together, beautiful things can happen. It starts with an idea, a problem that begs for a solution, and then the work on finding the answers begins.

Lindsey Robertson, BSN, RN, is a staff nurse who has worked in the surgical intensive care unit at Vanderbilt University Hospital for eight years. She saw that oftentimes the decision to withdraw mechanical ventilation had been made and once everything is turned off, the patient typically dies within five minutes. "In some cases, the ventilator, certain drips, and countless other machines are the only reason they have not died," she says.

The shift from curative measures to compassionate ones, she notes, is a difficult thing for clinicians to deal with. She also noticed there were no real models or standardized processes for patients who are taken off support and die less than 24 hours later. By creating guidelines, she thought she could make the process easier for the clinical team, including physicians and nurses, and in turn help interns, residents, and new nurses who may be experiencing their first patient death. She also wanted a team approach for all the disciplines involved.

Robertson engaged the help of Barbara Gray, BSN, RN, quality consultant, to create an improved standardized system and to help guide it through the various committees it would have to pass muster with before becoming a unit-based hospital policy.

Gray says initially they looked at guidance from the American Association of Critical Care Nurses and the Robert Wood Johnson Foundation. But a lot of what they found was more about palliative or long-term care. "In our work, it's just more about, 'OK, once the decision is made, how do we do this? What do we do?'" she says.

One option that was suggested to help increase ICU bed availability was moving patients upstairs to complete the dying process, once the decision to withdraw was made. However, Robertson says, "My concern with moving the patient is that the family has developed rapport with the nurse in the ICU and with the ICU medical team, and if you send them upstairs to a new nurse and a different medical team, they will lose that compassionate continuity. Also, the majority of our withdrawals happen quickly, and most patients die within a 30-minute period of turning everything off.

"My preference is to educate the nurses in our ICU to deal with these situations and keep it in-house where we can deal with it compassionately, with a family who knows us and has been dealing with us," she says.

Once a patient and his or her family decides to withdraw support, the physician initiates the comfort care order set and nurses print the guidelines for withdrawal of life support as a reference. Robertson says the discussion between the nurse and the patient and family involves a lot of questions, and because it's a stressful time, nurses can get overwhelmed or forget the myriad details. The guidelines serve as reminders of all the questions that need to be touched on, including:

  • Does the family want a pastor or religious leader there?
  • Would additional family members like to be there?
  • Would the family like to be present when the patient passes, and would they like to see the patient after he or she expires and is cleaned?
  • What the family should expect as far as physical changes as the patient dies.

"We have things like that outlined so that a nurse can follow the process and make sure that everything is covered for the comfort of the family and patient so that things will go as smoothly as possible. There's no such thing as a good death. But it can be without conflict and be a peaceful memory," she says.

The guidelines include every member of the team who needs to be present and prompts to ensure everything that is needed, such as drugs, is in the room.

"We can even turn off the monitor alarms and turn off the monitor screen in the room to remove the stress of watching a dying heart. Some of our patients are in isolation, which means the family members are wearing gloves and gowns in the room. The guidelines remind the nurse to tell the family to remove their gloves, lower the bedrails, and touch their family member. These are simple things that can be forgotten that need to be implemented," Robertson says.

Robertson and Gray also revised an existing order set to assist in the management of sedation and ventilation. The guidelines are part of the surgical critical care manual, so physicians have become familiar with them. New residents are introduced to the guidelines when they arrive each month. And every six months, Robertson sends out a staffwide email to remind people that the guidelines are available and where they are located electronically.

Providing a comfortable space for family is at the helm of the initiative, which includes reminders that:

  • privacy is provided;
  • patients are monitored for pain or discomfort;
  • liberalized visitation;
  • ensuring the family is comfortable — that chairs are provided, gloves are removed, and the bedrails are lowered;
  • all unnecessary equipment is removed;
  • doors are closed to keep the room as quiet as possible;
  • the cardiac monitor is turned off.

Robertson and Gray say they have received positive feedback from both families and the clinical team including the nurses, respiratory therapists, residents, fellows, and attending physicians.

The guidelines that were developed "give everybody kind of a sigh of relief if you will. 'OK, there's a process for doing this. We don't have to create something. If we don't know what to do, here it is written down for us.' And so that's really helped a lot," Gray says.

She says the support from each committee the guidelines passed through was there. "But [leadership has] so many irons in the fire so many times it takes someone with a real special interest to just kind of keep nudging or pushing forward," like Robertson, she says.