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A pilot audit of the process of end-of-life decision-making in the intensive care unit.

BACKGROUND
Withdrawal of potentially life-prolonging treatments is a common procedure in most intensive care units. Until recently, quality improvement activities have been hampered by the absence of a clear sense of "best practice" in this complex area.


OBJECTIVE
This pilot audit addresses the feasibility of developing an end-of-life (EOL) decision-making audit and quality improvement tool and applying it in the intensive care setting.


METHODS
Between November 2005 and April 2006, treatment was withdrawn from 47 patients in our ICU. Their charts were audited, and a structured interview was conducted with the intensivist who documented the decision. We defined treatment withdrawal as the cessation of mechanical ventilation and all other forms of life support in the anticipation of the patient's death.


RESULTS
55% of ICU deaths were the result of treatment withdrawal. Overwhelmingly, treatment failure or futility was the reason cited for withdrawal. There were no cases of conflict between the medical team and the patient's family. The level of confidence among intensivists about EOL decision-making was high. Consultation with ICU colleagues was rated as the most helpful factor in decisionmaking. Intensivists wished for earlier and more active support from the admitting medical officers in decisionmaking. Strong support for advance planning and for audit of EOL decision-making was highlighted.


CONCLUSIONS
A current ICU quality improvement review lists EOL management as a possible audit item (Curtis et al. Crit Care Med 2006; 34: 211). Our study demonstrated the feasibility of developing a quality improvement tool for EOL decision-making and applying it in the intensive care setting. As evidence about the process of EOL decisionmaking accumulates, that process should become a component of quality assurance audit in intensive care.