Care at the end of life - Medication use during the final 12 hours in the ICU

Purpose: Approximately 10-25% of patients admitted to intensive care units (ICUs) die. Despite this significant mortality rate, there is a paucity of data available regarding the nature of death - e.g. whether mechanical ventilation was discontinued, what medications were used, in what doses, etc. To examine medication choices and practices of individual intensivists, we reviewed medication use in the final 12 hours for all deaths occurring in two medical-surgical-neurosurgical ICUs within a one year timeframe. Methods: Between July 1996 and June 1997, 10 intensivists cared for patients in the ICUs. The medical records for all patients coded as dying while in the ICU were identified through the Health Records Department. Data collected from each chart included the following: age; gender; date of ICU admission; date and time of death; ICU length of stay; attending intensivist at time of death; and all medication use for the preceding 12 hours if in the intensive care unit. Categorical data were analyzed using Chi square or Fisher's exact test as appropriate. Continuous data was analyzed by t-test, ANOVA, or repeated measures ANOVA as appropriate. Where multiple comparisons were employed, a Bonferroni correction was applied. Differences were accepted as statistically significant when p<0.05. Results: For the 12 month period, a total of 1,327 patients were admitted to the ICUs. Of these, 1,153 survived (87%). No differences in the mortality rate or rate of care withdrawal were detected among the 10 intensivists. Patients in whom care was withdrawn were older, more likely to have been admitted for a surgical procedure, and more likely to be receiving mechanical ventilation at the time of death. In the 12 hours preceding death, no differences were detected in the incidence of use of inotropes, antibiotics, diuretics, sedatives, or analgesics among attending physicians, but the use of muscle relaxants was significantly higher for 2 physicians. Significant differences were found for hourly rate of drug administration for sedatives and analgesic agents in patients in whom care was withdrawn (morphine 4 mg/hr average dose) or was not withdrawn (morphine 1.5 mg/hr) and substantial physician practice variations were detected. Conclusions: Considerable variability exists among physicians as regards sedative and analgesic drug administration in the 12 hours prior to death in the ICU. Clinical Implications: The extent of variability in practice lends support to educational initiatives and development of practice guidelines to ensure more consistent approaches to end of life care.