Continuous and deep sedation until death after a decision to withdraw life-sustaining therapies in intensive care units: A national survey

Abstract

Background: Continuous and deep sedation until death is a much highly debated end-of-life practice. France is unique in having a regulatory framework for it. However, there are no data on its practice in intensive care units (ICUs). Aim: The aim is to describe continuous and deep sedation in relation to the framework in the specific context of withdrawal of life-sustaining therapies in ICUs, that is, its decision-making process and its practice compared to other end-of-life practices in this setting. Design and setting: French multicenter observational study. Consecutive ICU patients who died after a decision to withdraw life-sustaining therapies. Results: A total of 343 patients in 57 ICUs, 208 (60%) with continuous and deep sedation. A formalized procedure for continuous and deep sedation was available in 32% of the ICUs. Continuous and deep sedation was not the result of a collegial decision-making process in 17% of cases, and did not involve consultation with an external physician in 29% of cases. The most commonly used sedative medicines were midazolam (10 [5–18] mg h−1) and propofol (200 [120–250] mg h −1). The Richmond Agitation Sedation Scale (RASS) was −5 in 60% of cases. Analgesia was associated with sedation in 94% of cases. Compared with other end-of-life sedative practices ( n = 98), medicines doses were higher with no difference in the depth of sedation. Conclusions: This study shows a poor compliance with the framework for continuous and deep sedation. It highlights the need to formalize it to improve the decision-making process and the match between the intent, the practice and the actual effect.

Bispectral Index monitoring of palliative sedation for home withdrawal of tracheostomy ventilation: A case report

“…Of note, concerns have been raised in the intensive care literature regarding symptoms and doses of medications used in the withdrawal of mechanical ventilation at end of life. 5,6 The COVID-19 pandemic has also focussed attention on the planning and practices of mechanical ventilation withdrawal in respiratory failure. 7 In Australia and many other countries, the withdrawal of life-sustaining treatment, made by a person who has the mental capacity to make that decision, is legal and not regarded as suicide, with the cause of death being attributed to the patient's underlying condition.…”