Supporting families of patients who die in adult intensive care: A scoping review of interventions

BACKGROUND

Families who perceive themselves as prepared for an impending death experience reduced psychological burden during bereavement. Understanding which interventions promote death preparedness in families during end-of-life care in intensive care will inform future intervention development and may help limit the burden of psychological symptoms associated with bereavement.

AIM

To identify and characterise interventions that help prepare families for the possibility of death in intensive care, incorporating barriers to intervention implementation, outcome variables and instruments used.

DESIGN

Scoping review using Joanna Briggs methodology, prospectively registered and reported using relevant guidelines.

DATA SOURCES

A systematic search of six databases from 2007 to 2023 for randomised controlled trials evaluating interventions that prepared families of intensive care patients for the possibility of death. Citations were screened against the inclusion criteria and extracted by two reviewers independently.

RESULTS

Seven trials met eligibility criteria. Interventions were classified: decision support, psychoeducation, information provision. Psychoeducation involving physician-led family conference, emotional support and written information reduced symptoms of anxiety, depression, prolonged grief, and post-traumatic stress in families during bereavement. Anxiety, depression, and post-traumatic stress were assessed most frequently. Barriers and facilitators to intervention implementation were seldom reported.

CONCLUSION

This review provides a conceptual framework of interventions to prepare families for death in intensive care, while highlighting a gap in rigorously conducted empirical research in this area. Future research should focus on theoretically informed, family-clinician communication, and explore the benefits of integrating existing multidisciplinary palliative care guidelines to deliver family conference within intensive care.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care clinicians should consider innovative communication strategies to build family-clinician connectedness in remote pandemic conditions. To prepare families for an impending death, mnemonic guided physician-led family conference and printed information could be implemented to prepare families for death, dying and bereavement. Mnemonic guided emotional support during dying and family conference after death may also assist families seeking closure.

Bereavement Support on the Frontline of COVID-19: Recommendations for Hospital Clinicians

Deaths due to COVID-19 are associated with risk factors which can lead to prolonged grief disorder, post-traumatic stress, and other poor bereavement outcomes among relatives, as well as moral injury and distress in frontline staff. Here we review relevant research evidence and provide evidence-based recommendations and resources for hospital clinicians to mitigate poor bereavement outcomes and support staff. For relatives, bereavement risk factors include dying in an intensive care unit, severe breathlessness, patient isolation or restricted access, significant patient and family emotional distress, and disruption to relatives' social support networks. Recommendations include advance care planning; proactive, sensitive, and regular communication with family members alongside accurate information provision; enabling family members to say goodbye in person where possible; supporting virtual communication; providing excellent symptom management and emotional and spiritual support; and providing and/or sign-posting to bereavement services. To mitigate effects of this emotionally challenging work on staff, we recommend an organizational and systemic approach which includes access to informal and professional support.

A qualitative meta-synthesis investigating the experiences of the patient's family when treatment is withdrawn in the intensive care unit

AIM

To synthesize qualitative studies of patients' families' experiences and perceptions of end-of-life care in the intensive care unit when life-sustaining treatments are withdrawn.

DESIGN

Qualitative meta-synthesis.

DATA SOURCES

Comprehensive search of 18 electronic databases for qualitative studies published between January 2005 - February 2019.

REVIEW METHOD

Meta-aggregation.

RESULTS

Thirteen studies met the inclusion criteria. A conceptual 'Model of Preparedness' was developed reflecting the elements of end-of-life care most valued by families: 'End-of-life communication'; 'Valued attributes of patient care'; 'Preparing the family'; 'Supporting the family'; and 'Bereavement care'.

CONCLUSION

A family-centred approach to end-of-life care that acknowledges the values and preferences of families in the intensive care unit is important. Families have unmet needs related to communication, support, and bereavement care. Effective communication and support are central to preparedness and if these care components are in place, families can be better equipped to manage the death, their sadness, loss, and grief. The findings suggest that health professionals may benefit from specialist end-of-life care education to support families and guide the establishment of preparedness.

IMPACT

Understanding the role and characteristics of preparedness during end-of-life care will inform future practice in the intensive care unit and may improve family member satisfaction with care and recovery from loss. Nurses are optimally positioned to address the perceived shortfalls in end-of-life care. These findings have implications for health education, policies, and standards for end-of-life care in the intensive care unit.

Sedation practice and discomfort during withdrawal of mechanical ventilation in critically ill patients at end-of-life: a post-hoc analysis of a multicenter study

PURPOSE

Little is known on the incidence of discomfort during the end-of-life of intensive care unit (ICU) patients and the impact of sedation on such discomfort. The aim of this study was to assess the incidence of discomfort events according to levels of sedation.

METHODS

Post-hoc analysis of an observational prospective multicenter study comparing immediate extubation vs. terminal weaning for end-of-life in ICU patients. Discomforts including gasps, significant bronchial obstruction or high behavioural pain scale score, were prospectively assessed by nurses from mechanical ventilation withdrawal until death. Level of sedation was assessed using the Richmond Agitation-Sedation Scale (RASS) and deep sedation was considered for a RASS - 5. Psychological disorders in family members were assessed up until 12 months after the death.

RESULTS

Among the 450 patients included in the original study, 226 (50%) experienced discomfort after mechanical ventilation withdrawal. Patients with discomfort received lower doses of midazolam and equivalent morphine, and were less likely to have deep sedation than patients without discomfort (59% vs. 79%, p < 0.001). After multivariate logistic regression, extubation (as compared terminal weaning) was the only factor associated with discomfort, whereas deep sedation and administration of vasoactive drugs were two factors independently associated with no discomfort. Long-term evaluation of psychological disorders in family members of dead patients did not differ between those with discomfort and the others.

CONCLUSION

Discomfort was frequent during end-of-life of ICU patients and was mainly associated with extubation and less profound sedation.

How is life support withdrawn in intensive care units: A narrative review

PURPOSE

Decisions to withdraw life-sustaining therapy (WDLS) are relatively common in intensive care units across Canada. As part of preliminary work to develop guidelines for WDLS, we performed a narrative review of the literature to identify published studies of WDLS.

MATERIALS AND METHODS

A search of MEDLINE and EMBASE databases was performed. The results were reviewed and only articles relevant to WDLS were included. Any references within these articles deemed to be relevant were subsequently included.

RESULTS

The initial search identified 3687 articles. A total of 100 articles of interest were identified from the initial search and a review of their references. The articles were primarily composed of observational data and expert opinion. The information from the literature was organized into 6 themes: preparation for WDLS, monitoring parameters, pharmacologic symptom management, withdrawing life-sustaining therapies, withdrawal of mechanical ventilation, and bereavement.

CONCLUSIONS

This review describes current practices and opinions about WDLS, and also demonstrates the significant practice variation that currently exists. We believe that the development of guidelines to help increase transparency and standardize the process will be an important step to ensuring high quality care during WDLS.

[Decision conflicts with relatives in the intensive care unit]

BACKGROUND

If medicine is coming close to its limits conflicts sometimes occur. Most conflicts in the intensive care unit (ICU) involve the medical team and patients' relatives. In particular decisions about withholding and withdrawing life-sustaining therapy lead to conflicts. Decisions about limiting life-sustaining treatment are burdened by conflicts and put an enormous strain particularly on relatives.

AIM

Illustration of currently available studies and existing recommendations on how to manage potentially conflict-laden decision-finding discussions on the ICU are presented.

MATERIAL AND METHODS

This article is based on a selective literature research in the PubMed database.

RESULTS

Studies have been carried out to evaluate posttraumatic stress disorders in relatives who were involved in life-limiting treatment decisions. Conflicts on the ICU put an emotional strain on relatives. Evidence-based recommendations are available regarding physicians' attitudes during discussions about therapy decisions, communication style and other contextual factors. Study results show that the emotional stress level relatives have to endure can be reduced if conversations between patients' families and the clinical personnel were conducted according to these recommendations. The involvement of a clinical ethics committee can prevent conflicts and has been shown to have no impact on the mortality rate but does decrease the time life-sustaining measures were unsuccessfully pursued.

CONCLUSION

To prevent conflicts between the medical personnel and patients' relatives on the ICU, a timely, congruent and empathic conversation style in an appropriate, quiet environment is essential. Consultation with clinical ethics committees is recommended to de-escalate disputes.

Questionnaires on Family Satisfaction in the Adult ICU: A Systematic Review Including Psychometric Properties

OBJECTIVES

To perform a systematic review of the literature to determine which questionnaires are currently available to measure family satisfaction with care on the ICU and to provide an overview of their quality by evaluating their psychometric properties.

DATA SOURCES

We searched PubMed, Embase, The Cochrane Library, Web of Science, PsycINFO, and CINAHL from inception to October 30, 2013.

STUDY SELECTION

Experimental and observational research articles reporting on questionnaires on family satisfaction and/or needs in the ICU were included. Two reviewers determined eligibility.

DATA EXTRACTION

Design, application mode, language, and the number of studies of the tools were registered. With this information, the tools were globally categorized according to validity and reliability: level I (well-established quality), II (approaching well-established quality), III (promising quality), or IV (unconfirmed quality). The quality of the highest level (I) tools was assessed by further examination of the psychometric properties and sample size of the studies.

DATA SYNTHESIS

The search detected 3,655 references, from which 135 articles were included. We found 27 different tools that assessed overall or circumscribed aspects of family satisfaction with ICU care. Only four questionnaires were categorized as level I: the Critical Care Family Needs Inventory, the Society of Critical Care Medicine Family Needs Assessment, the Critical Care Family Satisfaction Survey, and the Family Satisfaction in the Intensive Care Unit. Studies on these questionnaires were of good sample size (n ≥ 100) and showed adequate data on face/content validity and internal consistency. Studies on the Critical Care Family Needs Inventory, the Family Satisfaction in the Intensive Care Unit also contained sufficient data on inter-rater/test-retest reliability, responsiveness, and feasibility. In general, data on measures of central tendency and sensitivity to change were scarce.

CONCLUSIONS

Of all the questionnaires found, the Critical Care Family Needs Inventory and the Family Satisfaction in the Intensive Care Unit were the most reliable and valid in relation to their psychometric properties. However, a universal "best questionnaire" is indefinable because it depends on the specific goal, context, and population used in the inquiry.

The relationship between organizational culture and family satisfaction in critical care

OBJECTIVES

Family satisfaction with critical care is influenced by a variety of factors. We investigated the relationship between measures of organizational and safety culture, and family satisfaction in critical care. We further explored differences in this relationship depending on intensive care unit survival status and length of intensive care unit stay of the patient.

DESIGN

Cross-sectional surveys.

SETTING

Twenty-three tertiary and community intensive care units within three provinces in Canada.

SUBJECTS

One thousand two-hundred eighty-five respondents from 2374 intensive care unit clinical staff, and 880 respondents from 1381 family members of intensive care unit patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Intensive care unit staff completed the Organization and Management of Intensive Care Units survey and the Hospital Survey on Patient Safety Culture. Family members completed the Family Satisfaction in the Intensive Care Unit 24, a validated survey of family satisfaction. A priori, we analyzed adjusted relationships between each domain score from the culture surveys and either satisfaction with care or satisfaction with decision-making for each of four subgroups of family members according to patient descriptors: intensive care unit survivors who had length of intensive care unit stay <14 days or >14 days, and intensive care unit nonsurvivors who had length of stay <14 days or ≥14 days. We found strong positive relationships between most domains of organizational and safety culture, and satisfaction with care or decision-making for family members of intensive care unit nonsurvivors who spent at least 14 days in the intensive care unit. For the other three groups, there were only a few weak relationships between domains of organizational and safety culture and family satisfaction.

CONCLUSIONS

Our findings suggest that the effect of organizational culture on care delivery is most easily detectable by family members of the most seriously ill patients who interact frequently with intensive care unit staff, who are intensive care unit nonsurvivors, and who spend a longer time in the intensive care unit. Positive relationships between measures of organizational and safety culture and family satisfaction suggest that by improving organizational culture, we may also improve family satisfaction.

Qualitative research: adding drive and dimension to clinical research

Qualitative research and its methods stem from the social sciences and can be used to describe and interpret complex phenomena that involve individuals' views, beliefs, preferences, and subjective responses to places and people. Thus, qualitative research explores the many subjective factors that may influence patient outcomes, staff well-being, and healthcare quality, yet fail to lend themselves to the hypothesis-testing approach that characterizes quantitative research. Qualitative research is valuable in the intensive care unit to explore organizational and cultural issues and to gain insight into social interactions, healthcare delivery processes, and communication. Qualitative research generates explanatory models and theories, which can then serve to devise interventions, whose efficacy can be studied quantitatively. Thus, qualitative research works synergistically with quantitative research, providing new impetus to the research process and a new dimension to research findings. Qualitative research starts with conceptualizing the research question, choosing the appropriate qualitative strategy, and designing the study; rigorous methods specifically designed for qualitative research are then used to conduct the study, analyze the data, and verify the findings. The researcher is the data-collecting instrument, and the data are the participants' words and behaviors. Data coding methods are used to describe experiences, discover themes, and build theories. In this review, we outline the rationale and methods for conducting qualitative research to inform critical care issues. We provide an overview of available qualitative methods and explain how they can work in close synergy with quantitative methods. To illustrate the effectiveness of combining different research methods, we will refer to recent qualitative studies conducted in the intensive care unit.

Family support at end of life

Much of the literature for end of life in the intensive care unit focuses on patients and their treatment. Families are usually present and should be a focus, as well as a resource, in end-of-life plans. Using categories from a recently published Society of Critical Care Medicine guideline on family support during an intensive care unit stay and 7 end-of-life domains, literature retrieved since 2000 was summarized. Topics addressed are decision making, spiritual and cultural support, emotional and practical support of families, including visitation and family preparation for death, and continuity of care.

End-of-life family conferences: rooted in the evidence

Critical care clinicians no longer consider family members as visitors in the intensive care unit. Family-centered care has emerged from the results of qualitative and quantitative studies evaluating the specific needs of families of patients dying in the intensive care unit. In addition, interventional studies have established that intensive and proactive communication empowers family members of dying patients, helping them to share in discussions and decisions, if they so wish. In addition to intensive communication, interventional studies have highlighted the role of nurses, social workers, and palliative care teams in reducing family burden, avoiding futile life-sustaining therapies, and providing effective comfort care. End-of-life family conferences are formal, structured meetings between intensivists and family members. Guidelines for organizing these conferences take into account the specific needs of families, including reassurance that the patient's symptoms will be adequately managed; honest clear information about the patient's condition and treatment; a willingness on the part of physicians to listen and respond to family members and to address their emotions; attention to patient preferences; clear explanations about surrogate decision making; and continuous, compassionate, and technically proficient attention to the patient's needs until death occurs. Means of improving end-of-life care have been identified in epidemiologic and interventional studies. End-of-life family conferences constitute the keystone around which excellent end-of-life care can be built.

A communication strategy and brochure for relatives of patients dying in the ICU

BACKGROUND

There is a need for close communication with relatives of patients dying in the intensive care unit (ICU). We evaluated a format that included a proactive end-of-life conference and a brochure to see whether it could lessen the effects of bereavement.

METHODS

Family members of 126 patients dying in 22 ICUs in France were randomly assigned to the intervention format or to the customary end-of-life conference. Participants were interviewed by telephone 90 days after the death with the use of the Impact of Event Scale (IES; scores range from 0, indicating no symptoms, to 75, indicating severe symptoms related to post-traumatic stress disorder [PTSD]) and the Hospital Anxiety and Depression Scale (HADS; subscale scores range from 0, indicating no distress, to 21, indicating maximum distress).

RESULTS

Participants in the intervention group had longer conferences than those in the control group (median, 30 minutes [interquartile range, 19 to 45] vs. 20 minutes [interquartile range, 15 to 30]; P<0.001) and spent more of the time talking (median, 14 minutes [interquartile range, 8 to 20] vs. 5 minutes [interquartile range, 5 to 10]). On day 90, the 56 participants in the intervention group who responded to the telephone interview had a significantly lower median IES score than the 52 participants in the control group (27 vs. 39, P=0.02) and a lower prevalence of PTSD-related symptoms (45% vs. 69%, P=0.01). The median HADS score was also lower in the intervention group (11, vs. 17 in the control group; P=0.004), and symptoms of both anxiety and depression were less prevalent (anxiety, 45% vs. 67%; P=0.02; depression, 29% vs. 56%; P=0.003).

CONCLUSIONS

Providing relatives of patients who are dying in the ICU with a brochure on bereavement and using a proactive communication strategy that includes longer conferences and more time for family members to talk may lessen the burden of bereavement. (ClinicalTrials.gov number, NCT00331877.)

Cuidados al final de la vida en la unidad de cuidados intensivos pediátrica. Revisión de la bibliografía

INTRODUCTION

In the last few years, there has been growing concern in the literature about issues related to end-of-life care in pediatric intensive care units (PICUs), with special attention on the family/patient unit, communication, and a dignified death.

OBJECTIVE

To evaluate the experience and development of end-of-life care in PICUs through a literature review, by determining the type of studies that have been performed, their topics, the issues discussed, and their development in the last few years.

MATERIAL AND METHODS

Review of the medical literature in Medline and the database of the National Library of Medicine Gateway, using the key words from MeSH: "end of life", "pediatric intensive care", "critical care", "palliative care", "death", and "compassionate care". The earliest year of the search was 1990. The languages selected were English and Spanish. Inclusion criteria were the relationship with the topic to be studied, excluding articles with no abstract. Additional searches were made of references in selected articles.

RESULTS

Eighty-one articles were retrieved from the initial search. Of these, 43 were selected as the most relevant investigations in end-of-life care in ICUs and 18 placed special emphasis on the PICU. More than half of the articles (62 %) were reviews and the remaining articles were descriptive or observational studies. The number of publications increased after 1995. Most of the studies were performed in the USA or Canada and only three studies were performed in Spain.

CONCLUSIONS

In the last few years, several studies have been performed that reveal increasing concern about limits to therapeutic intervention and the need to improve end-of-life care in the PICU setting.

Most critically ill patients are perceived to die in comfort during withdrawal of life support: a Canadian multicentre study

PURPOSE

Most deaths in intensive care units (ICUs) follow a withdrawal of life support (LS). Evaluation of this process including the related perspectives of grieving family members is integral to improvement of palliation in the ICU.

METHODS

A prospective, multicentre, cohort study in six Canadian university-affiliated ICUs included 206 ICU patients (length of stay >or=48 hr) who received mechanical ventilation (MV) before LS withdrawal. We recorded modes, sequence and time course of LS withdrawal and drug usage (4 hr before; 4-8 hr and 8-12 hr before death). We asked a specified family member to assess patient comfort and key aspects of end-of life care.

RESULTS

MV was withdrawn from 155/206 (75.2%) patients; 97/155 (62.6%) died after extubation and 58/155 (37.4%) died with an airway in place. The most frequently used drugs and the cumulative doses [median (range)] in the four hours before death were: morphine 119/206, 24 mg, (2-450 mg); midazolam 45/206, 24 mg, (2-380 mg); and lorazepam 35/206, 4 mg, (1-80 mg). These doses did not differ among the three time periods before death. Of 196 responses from family members most indicated that patients were perceived to be either totally (73, 37.2%), very (48, 24.5%), or mostly comfortable (58, 29.6%). Times to death, morphine use and family members' perceptions of comfort were similar for each type of change to MV.

CONCLUSIONS

Most patients were perceived by family members to die in comfort during a withdrawal of LS. Perceptions of patient comfort and drug use in the hours before death were not associated with the mode or sequence of withdrawal of LS, or the time to death.

Deaths in a neonatal intensive care unit: a 10-year perspective

OBJECTIVE

To examine changes in the characteristics and management of infants dying in a regional neonatal intensive care unit in 1987-1988 vs. 1997-1998.

SETTING

The level III Neonatal Intensive Care Unit (NICU) at Rikshospitalet, Oslo, Norway, handles both regional and national referrals.

DESIGN/METHODS

The study was retrospective and observational. Patients who died in the neonatal intensive care unit were identified using our own and the hospital's data records. Charts were reviewed by the principal author.

RESULTS

The mortality rate relative to admissions decreased significantly from 1987-1988 to 1997-1998 (6.9% vs. 3.4%, p <.0001). Infants who died in 1997-1998 were more mature and had higher birth weights than those who died in 1987-1988 (34.0 +/- 5.5 vs. 32 +/- 6.0 wks gestational age [mean +/- sd], p <.05; and 2,186 +/- 1,207 vs. 1,699 +/- 1,038 g, p <.05). There was a significantly higher proportion of infants with complex congenital malformations among those who died in 1997-1998 (54% vs. 28%, p <.005). Forgoing intensive care treatment was more commonly associated with the process of dying in 1997-1998 than 10 yrs earlier (63.5% vs. 22.8%, p <.0001). Parental involvement in the process leading to a decision to forgo life support was more frequently described in the charts from 1997-1998 (72.7% vs. 23.8%, p <.001). During the last time period, parents were also present at the time of death significantly more often.

CONCLUSIONS

The mortality rate of sick infants decreased significantly between 1987-1988 and 1997-1998, showing the improvements in neonatal intensive care during that decade. In 1997-1998, congenital malformations had become the leading cause of death. Parental involvement in life-and-death questions seems to have become the rule, and almost two thirds of neonatal intensive care unit deaths followed a decision to forgo life support.

Caring for the family of the critically ill patient

Family's needs and considerations are an essential component of intensive care unit (ICU) care. Family satisfaction is related to clinician communication and decision making. Indeed, timely, honest communication is vital to the psychosocial health and satisfaction of the family. Conflict often arises within the family and between the family and the clinicians, over decision making. Again, good communication skills are critical to family satisfaction with decision making and comfort with the care received. Family members have numerous psychosocial changes, and may experience depression,anxiety, or anticipatory grief while their family member is dying in the ICU. Awareness of these conditions, providing support to the families, and allowing family access to the dying individual can assist with meeting the family's desire to see their family member have a peaceful death.

Communication with family members of patients dying in the intensive care unit

In intensive care units the patient is usually unconscious and/or incompetent so that the relationship shifts to the family. Interactions between caregivers and families usually follow one of three models. In the first model, a family representative receives information from the caregivers but does not participate in decisions or physical care. In the second model, the ICU caregivers attempt to provide care consistent with the patient's wishes and values as described by the family. In the third model, the family members communicate their own wishes, provide physical care to the patient, and participate in medical decision-making. After a description of the studies that measured the quality of information provided to ICU families and by discussing the extent to which respecting the principle of patient autonomy is feasible in the ICU, we will review the literature on studies that identified specific needs of families of dying patients and specific challenges faced by intensivists as they seek to inform the families of dying patients. The need for family-centered care and for a better communication within the patient-family-caregiver trio is also highlighted.

ICU nurses' preparation of families for death of patients following withdrawal of ventilator support

Intensive care unit nurses were asked how they prepared families for the death of their patient following withdrawal of mechanical ventilation. Forty-three descriptors were identified, of which 67.5% (n = 29) were "physical sensations and symptoms." Less frequently mentioned features of Self-Regulation Theory were temporal characteristics, environmental features, and causes of these signs. Eight descriptors mentioned by more than 50% of nurses were skin color changes (74%), skin temperature changes (74%), varying levels of consciousness (74%), effort with breathing (71%), variable timeframe to death (68%), breathing pattern (65%), sound during breathing (61%), and loss of bowel control/incontinence (52%).

Interhospital variability in satisfaction with withdrawal of life support: room for improvement?

OBJECTIVE

To develop instruments to measure the current level of satisfaction with the withdrawal of life support among nurses and respiratory therapists and to use these instruments to determine whether differences in satisfaction levels with the withdrawal of life support could be found among different institutions.

DESIGN

A multicenter, self-administered, questionnaire-based study.

SETTING

The intensive care units of three academic and 11 community hospitals.

SUBJECTS

A total of 412 critical care nurses and 117 respiratory therapists working in these intensive care units.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

After developing two similar questionnaires for critical care nurses and respiratory therapists, we assessed the reliability of the individual items for each questionnaire and only used those found to be reliable in the analyses. We found variability in the satisfaction level of critical care nurses among different intensive care units and among academic and community hospital intensive care units. Being involved in the plan for withdrawal of life support, comfort with the way discussions with the family had gone, comfort with patient sedation, and increasing experience with withdrawal of life support were items associated with increased nurse satisfaction. For respiratory therapists, there seemed to be similar differences among institutions in satisfaction level, although numbers were limited. Having the physician explain the plan to them and becoming more comfortable with withdrawal of life support as a result of increased experience were found to be associated with increased satisfaction levels for respiratory therapists.

CONCLUSIONS

Satisfaction levels of intensive care unit nurses and respiratory therapists with the process of withdrawing life support vary among institutions. This variation may represent an opportunity for improvement in the process of withdrawing life support within this region.