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.