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Kirchhoff, K.T., & Kowalkowski, J.A. (2010). Current practices for withdrawal of life support in intensive care units.

Kirchhoff, K.T., & Kowalkowski, J.A. (2010). Current practices for withdrawal of life support in intensive care units. American Journal of Critical Care, 19, 532-541.

Research question or purpose

The researchers examined withdrawal of life support practices in intensive care units in the United States from the perspective of critical care nurses, including perceptions of educational preparation for withdrawal and support for nurses in this process.

Research design

Questionnaire survey design.


With the assistance of the American Association of Critical Care Nurses (AACN), a random sample of 1,000 bedside nurses from the AACN member list was obtained by the researchers. To be eligible for the study, the nurses had to work in an intensive care unit (ICU) in the United States and provide care to adult patients.


The eligible sample for the study was 981 nurses, and a total of 475 nurses responded to the survey (48.4% response rate). The respondents were predominantly female (90.8%), with a median age of 48 years, a median of 22 years of experience as a registered nurse, and a median of 18 years of experience in critical care. Respondents worked a median of 36 hours per week in various types of ICUs (32.5% in ICU/coronary care units, 29.2% in medical and/or surgical ICUs, and 21.8% in cardiovascular/ cardiovascular surgery/coronary care units), with the majority working day shift (60%) in not-for-profit hospitals (73.2%).


The researchers developed a 48-item (16-page) questionnaire, consisting of multiple-choice and short-answer questions. Questions explored nurses' educational preparation for and experience with withdrawal of life support, unit practices related to withdrawal, supports available to nurses, and nurses' role in family conferences. The questionnaire was pilot-tested with six ICU nurses and reviewed by survey research experts, then revised based on their feedback. Once approved by a university research ethics board, the questionnaire was mailed out to the sample of nurses with a stamped return envelope. After two weeks, a reminder postcard was mailed out, followed three weeks later by a second questionnaire, to those nurses who had not submitted a response. Frequencies and descriptive statistics were calculated using SPSS version 16.0.

Main findings

The majority of respondents (77.5%) had been involved in up to five withdrawals of life support in the year prior to the survey, with 19.7% involved in up to 15, and 2.9% in more than 15.

In terms of the process of withdrawing life support, 87.5% of respondents indicated they attended family conferences when withdrawal was discussed, and 11.3% reported they initiated the conferences. Not one respondent reported using clinical practice guidelines for withdrawal and only 17.8% indicated that a form designed for this process was used in their unit. Nurses' actions were guided by physicians' orders (63.8%), care plans (20%), and standing orders (11.8%). Respondents reported experiencing emotional (66.1%), ethical (46.4%), and procedural (34.6%) difficulties with the process of withdrawing life support. They felt most supported emotionally by other nurses (49.8% always and 38.2% usually, n=406) and pastoral/spiritual care staff (20.9% always and 29.5% usually, n=397) during withdrawal and by other nurses (43.3% always and 43.3% usually, n=416) and their own family members (25.6% always and 26.9% usually, n=391) after withdrawal. A number of respondents indicated that patients' family members provided them with emotional support during (11.3% always and 33.8% usually, n=397) and after (10.9% always and 36.5% usually, n=395) withdrawal.

With regard to educational preparation, only 3.2% (n=467) of respondents reported that they felt confident or very confident in their ability to care for patients during withdrawal after their basic nursing education (41.8% were not confident at all), while 29% (n=461) reported feeling confident or very confident after critical care orientation. When asked about content related to the withdrawal of life support, 78.7% (n=451) of respondents indicated that no courses were offered covering this process in their basic educational programs and 63.1% (n=463) indicated that they had not received any training related to this process during orientation for their work in critical care.


The researchers found "deficiencies in training, support, and guidance" (p. 540) for critical care nurses who care for patients as life-sustaining therapies are withdrawn. Links are made between participation in this process and burnout, particularly given the lack of preparation for and policies related to treatment withdrawal, and the authors put forward an argument for improvements in the education of nurses and standardization of procedures based on practice guidelines and evidence.


This study is an interesting extension of the work of Karin Kirchhoff and colleagues on end-of-life care in the ICU (Beckstrand, Callister, & Kirchhoff, 2006; Kirchhoff, Palzkill, Kowalkowski, Mork, & Gretarsdottir, 2008; Kirchhoff et al., 2002). The strengths of Kirchhoff et al.'s (2008) study include the use of a small number of ICU nurses and experts in survey development to assess the questionnaire prior to sending it out and the use of a random sample of nurses. The researchers provide a solid discussion of the limitations of the study, including concerns regarding the clarity of some questions, the length of the questionnaire, and selection bias, given that all respondents were members of AACN. One limitation not discussed is the absence of evidence of open-ended questions to enable respondents to explain some of their answers. While it is useful to learn that a high percentage of nurses reported emotional, ethical, and procedural difficulties in the withdrawal process, it is also important to understand the nature of those difficulties, information best obtained through follow-up open-ended questions. The same holds true for the data presented regarding emotional support. We learn who provides the most support to nurses in this process, but would also benefit from knowing what it is that nurses, other team members, and patients' family members do to make nurses feel supported. These data may have been collected, but it is not presented in the report.

The findings of Kirchhoff et al.'s (2008) study draw attention to concerns regarding nurses' preparation for withdrawing life support in ICUs in the United States and the guidance provided to nurses in this process. One wonders how similar or different the responses to this questionnaire might be in Canada. There have been calls in this country for more education for nurses and physicians, quality improvement initiatives, and research related to end-of-life care in the ICU (Canadian Association of Critical Care Nurses, 2001; Cook, Rocker, & Heyland, 2004; Mawdsley & Northway, 2007). Indeed, end-of-life care was chosen as an area for improvement by the Canadian ICU Collaborative for Patient Safety (Mawdsley & Northway, 2007). The Canadian Nurses Association (2008) has identified that nurses have "an important and integral contribution to make in the provision and enhancement of end-of-life care" (p. 1). The authors of this study reinforce that we (e.g., educators, members of the interdisciplinary team, administrators, researchers) have work to do to assist and support critical care nurses in the pursuit of quality end-of-life care in the ICU. ft


Beckstrand, R.L., Callister, L.C., & Kirchhoff, K.T. (2006). Providing a "good death": Critical care nurses' suggestions for improving end-of-life care. American Journal of Critical Care, 15, 38-45.

Canadian Association of Critical Care Nurses. (2001). Withholding and withdrawing of life support. Retrieved from documents/pdf/publications/PS96_End_ of_Life_e.pdf

Canadian Nurses Association. (2008). Position statement: Providing nursing care at the end of life. Retrieved from http:// statements/ps2001.html

Cook, D., Rocker, G., & Heyland, D. (2004). Dying in the ICU: Strategies that may improve end-of-life care. Canadian Journal of Anesthesia, 51, 266-272.

Kirchhoff, K.T., Palzkill, J., Kowalkowski, J., Mork, A., & Gretarsdottir, E. (2008). Preparing families of intensive care patients for withdrawal of life support: A pilot study. American Journal of Critical Care, 17, 113-121.

Kirchhoff, K.T., Walker, L., Hutton, A., Spuhler, V., Cole, B.V., & Clemmer, T. (2002). The vortex: Families' experiences with death in the intensive care unit. American Journal of Critical Care, 11, 200-209.

Mawdsley, C., & Northway, T. (2007). The Canadian ICU Collaborative: End-of-life care in the ICU: Does end-of-life care get enough attention in your ICU? Dynamics, 18(4), 32-33.

Marie Edwards, RN, PhD, Assistant Professor, Faculty of Nursing, University of Manitoba
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Author:Edwards, Marie
Geographic Code:1USA
Date:Mar 22, 2011
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