• Laurent Holzapfel, Guy Demingeon, Bonnavy Piralla, Loïc Biot, and Brigitte Nallet.
• Service de réanimation, Centre Hospitalier, Route de Paris, 01012 Bourg en Bresse, France. lholzapfel@ch-bourg01.fr
• Intensive Care Med. 2002 Sep 1;28(9):1309-15.

ObjectiveTo describe a four-step protocol for withholding and withdrawal of life support (WH/WDLS) in intensive care unit (ICU) terminal patients.DesignObservational study.SettingA 10-bed ICU of a general hospital.PatientsEighty-three patients out of 475 consecutive patients admitted over a 1 year period had WH/WDLS.InterventionsThe healthcare team chose a pattern of treatment limitation on a four-step protocol for every patient every day. There were four alternatives: group 1: no limitation of care; group 2: patient designated do not resuscitate (DNR) and pressors limited to dopamine at a maximum dose of 20 microg/kg per min; others therapies were continued; group 3: active withdrawal of all therapy except comfort care, i.e., the patient continued to receive nursing, sedation/analgesia, hydration and mechanical ventilation with FIO2=0.21 and no positive end-expiratory pressure (PEEP). Sedation was adjusted to Ramsay 3-4. The group 4 was treated the same as group 3 except that minute ventilation was 5 l/min and sedation/analgesia adjusted to Ramsay 6. WH/WDLS was performed only if the full ICU staff and all family members agreed with the procedure. WH/WDLS was documented in the patient's chart.ResultsWithholding and withdrawal of life support was performed in 83 patients (17%): 25 patients in group 2 (15 deaths), 36 patients in group 3 (36 deaths) and 22 patients in group 4 (22 deaths). Finally, 73 patients died after WH/WDLS. ICU stay was 10+/-17 days, time from admission to WH/WDLS was 184+407 h and time from WH/WDLS to death was 64+/-84 h.ConclusionThis four-step protocol may promote medical decision making on end-of-life care.

21 keywords...

hide…