Withdrawal of active treatment in intensive care: what is stopped - comparison between belief and practice

To assess the methods of withdrawal of active treatment in intensive care patients and to compare surveyed practice with the beliefs of medical and nursing staff.

Staff beliefs were assessed prospectively using an anonymous questionnaire. Withdrawal methods were assessed retrospectively by a review of the medical records of 40 consecutive patients who had treatment withdrawn.

A 14-bed mixed tertiary-referral intensive care unit, February to June 2008.

Results of the medical record review and questionnaire were compared.

11 medical and 45 nursing staff responded (78% and 53% response rate, respectively). Of the 56, 20% believed intravenous maintenance fluids should continue when it is decided to withdraw active treatment; 21% believed ventilation should continue, and approximately 40% believed electrocardiography and pulse oximetry monitoring should continue. Medical staff were more likely than nursing staff to recommend ceasing all treatment and monitoring. Audit of medical records showed that 38 of 40 patients (95%) had ongoing maintenance fluid administration at the time of death. All had respiratory support withdrawn, and one patient had all monitoring removed. Four patients (10%) had clear documentation of their not-for-resuscitation status, and 35 patients (88%) had documentation of a family meeting and the rationale for withdrawal.

These results suggest a wide disparity between belief and practice, with variable documentation regarding end-of-life decision-making and treatment of patients for palliation in the ICU. Several guidelines have been published that might improve end-of-life care. We recommend a standardised approach to improve communication between medical and nursing staff.