How Long Will This Take, Doc? Timing from End-of-Life Orders Until Death (QI628)

Abstract

•Justify use of an order set for withdrawal of life-sustaining treatment in the intensive care unit.•Propose means to reduce unwarranted variation in practice. Withdrawal of life-sustaining treatment (WLST) is a critically important time in the life of a patient and family and presents unique emotional pressure to all involved. The decision to redirect goals of inpatient care to focus on comfort is best supported by clear, evidence-based treatment. Use of an order set in the electronic health record (EHR) can facilitate best care for the dying patient. Assess time from use of a WLST order set to inpatient death with the goal of reducing variation in practice. One-year, single-center, retrospective cohort study across a large, nonprofit health system in central Ohio. All inpatient decedents for whom care measures were entered using an available WLST order set. Primary outcome was timing from orders being entered until death. Secondary analyses included stratification by presence of palliative consultation and by specialty of ordering provider. 690 patients met inclusion criteria. The median time from WLST orders to death was 3.8 hours. Of 690 patients, 312 (45%) received palliative consultation and median time was 3.9 hours; 378 (55%) without palliative consultation had median time of 3.6 hours (not statistically significantly different). There was no statistically significant difference in time from WLST orders to death between the three mutually exclusive groups: orders by palliative provider and palliative consult, orders by nonpalliative provider and palliative consult, and orders by nonpalliative provider and no palliative consult. Timing from use of a WLST order set to inpatient death was consistent with published studies. There were no statistically significant differences in our secondary analyses. We conclude appropriate timing from WLST to death and reduced variation in practice associated with use of an order set. Next steps include order set optimization as well as detailed analysis of medications received.