Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : 4.3 Implement Appropriate Ventilator Withdrawal Techniques : 4.3.4 Case Study - Queen Elizabeth II Health Sciences Centre

The Breakthrough Series team at Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, aimed to improve family satisfaction with patient care (in the ICU) and particularly with the management of pain, dyspnea, and sedation whenever life support is withdrawn and to achieve consistency in patient care. One of its most important activities was a study of variation in practice for ventilator cessation: Everyone involved had his or her own method.

In general, wide practice variation signals an opportunity for improvement. Usually, having as many ways to do something as there are people doing it is a sign that no one has really thought the process through and that no practice pattern will be implemented well by all.

Mechanical Weaning, Variations in Practice, Halifax, Nova Scotia. Weaning FiO2 during withdrawal of Life Support (Nurse Preferences), Halifax, Nova Scotia.

The variation in practice survey asked nurses to respond to a given scenario; it was not a study of actual practice variation. Through responses to the scenario, however, the team measured the amount of sedation nurses recommended and their preferences for weaning and titration of FiO2 at the time life support was withdrawn. The Breakthrough Series team found that 65 percent of nurses wanted single-step reduction in FiO2, while 31 percent preferred a graded reduction. The amounts of morphine and lorazepam nurses recommended using varied widely. Based on the survey results, the team developed a sedation algorithm and a ventilator withdrawal checklist.

In addition to the practice variation study, the Breakthrough Series team tried several changes, which it measured by:

  • Tracking intensity levels or scores for dyspnea, pain, and sedation
  • Conducting family satisfaction surveys during three separate periods
  • Making a quality-of-death review
 Percentage of Acceptable Symptom Scores at ICU Discharge, Halifax, Nova Scotia.
Withdrawal of Life Support Checklist
  1. Does the patient have a living will or a durable Power of Attorney for health issues?
    ____Yes ___No
    If yes, is the proposed decision to withdrawal life support in accordance with the wishes expressed in the living will or the durable Power of Attorney?
    ____Yes _____No
    Copy on the chart.
    ____Yes ____No


  2. Has the referring doctor been notified?
    ____Yes ____No


  3. Has the second staff physician’s opinion to withdrawal life support been obtained?
    ____Yes ____No


  4. If the patient is capable, has he/she been involved in the decision making process?
    ___Yes ____No


  5. If the patient is not capable or unconscious, has the next-of-kin/substitute decision maker been involved in the decision making process?
    ____Yes ____No


  6. Has the ICU doctor communicated the plan of care to the family?
    ____Yes ____No
    If No, why? e.g. unable to reach.


  7. Has the discussion been documented on the chart by:
    Physician_________________/Nurse__________
    _____Yes


  8. Has the Do Not Resuscitate Order been written?
    ____Yes When_________


  9. Has the patient and/or family had the opportunity to speak to a spiritual resource person?
    ____Yes ____Declined


  10. Are there any particular religious/cultural practices to be followed at the time of death?
    ____Yes ____No
    List:



  11. Where appropriate, have other consulting support services been notified?
    ____Yes ____Not Required


  12. Have comfort measures been implemented?
    ____Yes


  13. Has all other active treatment been withdrawn?
    ____Yes
Physician's SignatureNurse's Signature

Date_______________(Yyyy/Mm/Dd)
Reprinted with permission of Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia

<<< Previous Next >>> [ Go Up ]


order from Amazon.com

This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].

Sourcebook logo