# Intensive End-of-Life Care: Implementation of a Canadian Guideline-Based Order Set for the Withdrawal of Life-Sustaining Therapy in the Intensive Care Unit

## TL;DR

This study tested the use of a standardized care plan for end-of-life care in ICU based on Canadian guidelines to improve patient and family outcomes.

## Contribution

The study demonstrates the feasibility of implementing a multidisciplinary order set for end-of-life care in the ICU.

## Key findings

- The intervention improved symptom assessment using standardized tools during and after implementation.
- There was no change in sedative dosing or time to death before, during, or after implementation.
- Holistic care outcomes improved post-implementation despite increased paperwork burden.

## Abstract

An increasing number of patients receive end-of-life care in the intensive care unit (ICU). Death often occurs in the ICU after a decision has been made to withdraw life-sustaining therapies. In 2016, Downar et al. published Canadian consensus guidelines to standardize practices for withdrawal of life-sustaining therapy in the ICU. In this study, we sought to understand the feasibility and acceptability of implementing an order set, nursing flowsheet, and nursing care plan based on these guidelines in two ICUs in Saskatchewan, Canada.

We used a hybrid effectiveness-implementation design, engaging a steering committee of ICU health care providers and leadership to guide implementation. We conducted a six-month pilot implementation. We collected data in the three months pre-implementation, during the six-month implementation period, and for three months post-implementation. To evaluate implementation outcomes, we used the Consolidated Framework for Implementation Research to develop semi-structured interviews and feasibility surveys. To measure effectiveness outcomes, bedside nurses completed Quality of Death and Dying surveys, and we performed a patient chart review.

The intervention materials added to the burden of paperwork of bedside health care providers but helped them provide quality end-of-life care, meet the needs of patients and their families, and lessen ethical tensions between symptom control and hastening death. There was no difference in cumulative sedative dosing and time to death after extubation in the pre-implementation, implementation, or post-implementation periods. A significant increase in symptom assessment (pain, dyspnea, and agitation) using standardized tools was observed during the implementation and post-implementation periods. There was an improvement in holistic care outcomes post-implementation.

We implemented current Canadian best-practice guidelines for providing end-of-life care in the ICU using a multidisciplinary approach. This study offers insight into how standardized symptom assessment and medication titration can be incorporated into the complex ICU environment.