Improving Care at the End-of-Life: Benefits from Using A Standardized Order Form

Abstract & Commentary

Synopsis: A standardized withdrawal-of-life-support order form was viewed as helpful by physicians and nurses and changed medication delivery in a positive manner.

Source: Treece PD, et al. Crit Care Med. 2004;32: 1141-1148.

The study described the development and evaluation of a "withdrawal-of-life support" order form designed to address the recognized need to improve quality of care at the end of life. The form, developed by a task force of critical care nurses, physicians, social workers, and pharmacists, consisted of a 2-sided document with 4 parts. The front page included 3 sections. The first section listed preparations, eg, remove devices, document discussions with family, complete do-not-resuscitate orders, etc. The second section listed choices for sedation and analgesia with suggested dosages. The third section focused on steps to be taken at the bedside in regard to removing ventilator support and maintaining patient comfort. A second page summarized principles supporting these guidelines.

The study was implemented in 6 physically distinct ICUs (65 beds) located in a university-affiliated hospital. Almost all respondents found the form helpful (physicians = 95%; nurses = 84%), with the section on sedation and analgesia rated most highly (physicians = 93%; nurses 70%). Perceptions of the quality of dying and death did not change significantly (P = .54). However, total doses of narcotics and benzodiazepines increased in the hour before and after ventilator withdrawal and the hour before death (P < .03). There was no change in the median time from ventilator withdrawal to death (pre-intervention = 37 min; post-intervention = 39 min; P = .49)

Comment by Leslie A. Hoffman, RN, PhD

Approximately half of patients who die in the hospital are cared for in an ICU and almost 20% of hospital deaths occur in the ICU. In North America and Europe, withholding or withdrawing life-sustaining therapy precedes the large majority of these deaths. Prior studies document stress associated with such events when clinicians have concerns about quality of the dying experience. This study evaluated results of an intervention designed to improve system-wide care through the provision of guidelines and supporting principles. The form developed by the task force did not specify specific medications or dosages, but rather presented several options under each heading and category (http://depts.washington.edu/eolcare).

Those using the form found it very helpful. Perceptions of the quality of the dying experience did not change. However, there was a change in use of narcotics and benzodiazepines, with a significant increase in dosages of both medications after implementation of the order form. There was no difference in time from withdrawal of mechanical ventilation to death, supporting that patients received increased sedation to achieve comfort rather than to hasten death. There are several limitations to this study. The study used a retrospective comparison group and it was possible that factors other than the intervention changed practice. Second, the study was implemented in one institution and all practitioners did not return the survey instruments. It is possible that those who chose not to reply differed in their assessments. Finally, the study did not assess perceptions of family members. Nonetheless, the study supports the benefits of simple change that has the potential to positively effect an important aspect of critical care practice.

Leslie A. Hoffman, PhD, RN, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, and Associate Editor of Critical Care Alert.