The Use of Opioids and Sedatives and Time UntilDeath After Withdrawing Mechanical Ventilation andVasoactive Drugs in a Dutch Intensive Care UnitJelle L. Epker, MD, Jan Bakker, MD, PhD, and Erwin J. O. Kompanje, PhD
BACKGROUND: We studied the frequency of withdrawal of mechanical ventilation (MV) and/orvasoactive agents (VAs), the time until death, and dosages of opioids and sedatives in a Dutchacademic intensive care unit (ICU), and compared these practices with international observa-tions in this field.METHODS: Retrospective data were collected from the electronic and paper files of all patientswho died after withdrawal of treatment in a Dutch ICU between October 2006 and February 2007.RESULTS: In this period, 471 patients were admitted to the ICU, of whom 88 died (18%). In 60of these patients (68%), MV and/or VAs were withdrawn. This group represented 13% of the totalICU population. Of the 60 patients for whom MV and/or VAs were withdrawn, 54 (90%) died afterwithdrawal of MV (with or without VAs). Six (10%) died after withdrawal of VAs only, 33 (55%) afterwithdrawal of MV in combination with VAs, and 21 (35%) after withdrawal of MV only. Deathoccurred after withdrawal of MV in combination with VAs after a median of 30 minutes(interquartile range [IQR], 10–195 minutes). When only MV was discontinued, the median timeuntil death was 50 minutes (IQR, 15–530 minutes). When only VAs were withdrawn, patientsdied after a median of 45 minutes (IQR, 20–715 minutes). Ten patients (17%) did not receiveopioids or sedatives in their last hours. Fifty patients received opioids in their last hours.Fentanyl, with a median dosage at time of death of 100 �g/h, was the most frequently usedopioid. Forty (80%) of the 50 patients mentioned above received some kind of sedative untildeath. In the MV withdrawal group, 34 of the 54 patients (63%) received sedatives in the lasthours of their lives: 16 (27%) received midazolam (median, 10 mg/h), 12 (22%) propofol(median, 160 mg/h), and 6 (11%) lorazepam (2.0 mg/h). Sedatives were administered to allpatients in whom only VAs were withdrawn.CONCLUSIONS: Dutch patients who die in the ICU, or die after discharge from the ICU, die afterMV and/or VAs are withdrawn. When treatments are withdrawn, death follows within 1 hour inmost patients, which is a reflection of the severity of illnesses. At least 80% of patients receiveopioids, and 67% receive sedatives until death. Fentanyl is the most used opioid, whereasmidazolam is the most used sedative. Dosages of opioids and sedatives did not significantly exceedthe ranges described as usual in the international literature. (Anesth Analg 2011;112:628–34)
With the introduction and technological develop-ment of intensive care units (ICUs) as we knowthem now, patient survival has increased mark-
edly, as has our ability to postpone death for an undefinedperiod of time. Because of these developments, withhold-ing and withdrawing active treatment has become anacceptable practice in many countries, including the Neth-erlands.1–3 In this context, it is important to understand thatwithdrawal of treatment is not considered the same aseuthanasia in the Netherlands. In many countries, thisvision is shared; however, the debate on this issue iscertainly not conclusive.4,5 Although euthanasia is onlyjustified in certain well-defined circumstances in the Neth-erlands, many doctors have stated or believe that Dutch
doctors are more aggressive with life-ending treatmentsand withdrawals.
In the ICU, mechanical ventilation (MV) and adminis-tration of vasoactive agents (VAs) are the most frequentlyused life-sustaining treatments. When the use of resourcesis considered disproportionate, in the case of futility oftreatment, or at the request of the patient, the medical staffmay decide to withdraw these treatments, which results indeath of the patient within hours or days in almost allcases.6 The severity of illness and organ failure and thekind of treatment that is withdrawn are strongly correlatedwith the time until death.7
Withdrawal of life-sustaining treatment can result indistress, pain, restlessness, spasms, breathlessness, anddeath rattle. Key quality measures for end-of-life careinclude the timely assessment and effective treatment ofthese physical symptoms.8–10
Pain and distress symptoms are normally prevented orsuppressed with opioids, sedatives, and other selectedmedications. The supposed contribution of the dosage levelof these medications to the time until death is still thesubject of much discussion.11 However, a growing body ofevidence suggests that after the administration of opioidsor sedatives, instead of shortening the dying process, dyingis prolonged.12–15
From the Department of Intensive Care Medicine, Erasmus MC Rotterdam,Rotterdam, The Netherlands.
Accepted for publication November 29, 2010.
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Jelle L. Epker, MD, Department of IntensiveCare Medicine, Erasmus MC Rotterdam, PO Box 2040, 3000 CA Rotterdam,The Netherlands. Address e-mail to [email protected].
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Our primary objective was to study the frequency of MVand/or VA withdrawal in anticipation of death, the fre-quency of opioid and sedative usage, the dosages ofopioids and sedatives, and the relation of these factors totime of death in our Dutch ICU. Second, we compared ourresults with the literature from other countries, becausethere have not been any comparative studies published onthis much-debated Dutch situation.
METHODSSampleWe collected data from all patients for whom life-sustaining treatment was withdrawn between October 2006and February 2007 in the 27-bed ICU of the Erasmus MCUniversity Hospital in Rotterdam, the Netherlands. Pa-tients were from a mixed population of medical, generalsurgical, neurological, neurosurgical, and trauma cases.
Data CollectionData were collected from both electronic and paper patientfiles. We gathered information on MV and/or VA with-drawal, time until death, and data concerning the admin-istration of fentanyl, morphine, midazolam, propofol, andlorazepam to patients whose MV and VAs were with-drawn. In the studied patient group, no other kinds ofsedatives, opioids, barbiturates, or muscle relaxants wereused in this period. Additionally, we gathered data onbackground characteristics of the patient (i.e., gender, age,length of stay in the ICU, length of stay in the ward afterdischarge from the ICU, Acute Physiology and ChronicHealth Evaluation [APACHE] II score, Sequential OrganFailure Assessment [SOFA] score, and primary admissiondiagnosis). For data collection from already deceased pa-tients who were not part of an interventional study, noinformed consent or additional approval was necessary,according to Dutch law.16 Treatment was withdrawn onlyafter multidisciplinary consent, when patients failed torespond to therapy in the case of multiple organ failure, orwhen the inevitable poor prognosis of the acute diseasebecame evident. Treatments were always withdrawn to-gether and not separately or consecutively. During thestudy period, there was no distinct, uniform protocol forend-of-life care in use by the ICU specialists.
AnalysisThe median duration of time until death after withdrawalof MV and VAs was calculated. Retrospectively, 3 groupscould be distinguished:
1. Patients in whom MV in combination with VAs waswithdrawn.
2. Patients in whom only MV was withdrawn, and noVAs were present.
3. Patients in whom only VAs were withdrawn, and noMV was present.
The median quantities and ranges of opioids and sedativesadministered per IV syringe pump infusion per hour andby bolus injection were registered. Analyses were con-ducted using SPSS 12.1 (SPSS, Inc., Chicago, IL).
RESULTSDuring the study period, 471 patients were admitted to theICU, 88 of whom died. Sixty of these 88 patients died afterwithdrawal of treatment, as shown in Figure 1. Twenty-eightpatients died spontaneously during the study period withoutwithdrawal of VAs and/or MV; these patients died as a resultof withholding therapy, unsuccessful cardiopulmonary resus-citation, cerebral herniation, fulminant therapy-resistant sep-tic shock, or massive unstoppable bleeding after trauma.
The general characteristics of the 60 patients who diedafter withdrawal of MV, VAs, or a combination of both areshown in Table 1.
MV and/or VA WithdrawalMV and/or VAs were withdrawn for 60 patients, repre-senting 13% of all ICU admissions. Because 88 patientsdied, 68% (n � 60) of this subset of patients died as a resultof withdrawal of MV and/or VAs.
MV was withdrawn in 11% (54) of all (471) ICU admis-sions, representing 61% of all patients who died. Of all patientsadmitted to the ICU, only 1.3% had only VAs withdrawn, whichrepresents 7% of all the patients who died in the ICU.
In 42 of the 60 patients, not only was MV terminated, butthe endotracheal tube was also removed. One patient had atracheostomy, which was not removed. Only 4 patients re-mained on the ventilator until death. Nine patients in whomMV was withdrawn were discharged to a special-care wardalmost directly after cessation of MV therapy. After trachealextubation, oxygen was not administered systematically.
Twenty-one (35%) of the 60 patients died after with-drawal of MV in combination with VAs, 33 (55%) died afterwithdrawal of MV alone, and 6 (10%) died after withdrawalof VAs only. Fifty patients died in the ICU, and 10 diedafter discharge from the ICU to a general ward.
SOFA scores were higher in patients for whom MV andVA support were withdrawn than in patients for whomonly MV was withdrawn (24 hours after admission: median11 vs 8, P � 0.03; 24 hours before death: 11 vs 7, P � 0.01).
Time Until Death After Withdrawal of Life-Sustaining TreatmentDeath occurred a median of 30 minutes (interquartile range[IQR], 10–195 minutes) after withdrawal of MV in combi-nation with VAs, as shown in Table 2. When only MV wasdiscontinued, the median time until death was 50 minutes(IQR, 15–530 minutes). In our small series in which onlyVAs were withdrawn, patients died after a median of 45minutes (IQR, 20–715 minutes). The differences in timeuntil death among these 3 withdrawal categories were notstatistically significant.
Patients who were transferred to the ward after thewithdrawal of MV died after a median of 63 hours (IQR,13–192 hours). The one patient who was transferred to theward after withdrawal of both VAs and MV died 35minutes after cessation of both therapies.
Sedatives and OpioidsTable 3 displays the cumulative quantities and dosagedistribution of sedatives and opioids in all patients (n � 60)who died after withdrawal of MV and/or VAs for all 3withdrawal categories and 3 different time periods.
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OpioidsFifty of the 60 patients (83%) who died after withdrawal oftherapy received some kind of opioid. Thirty-five patients
received fentanyl and 15 patients received morphine. Fen-tanyl was discontinued in 2 patients 4 hours before death.As a result, 33 patients received fentanyl until death. Themedian overall dosage for fentanyl was 88 �g/h, and themaximum dosage at any time was 500 �g/h.
Morphine was discontinued during withdrawal in 4patients; therefore, 11 patients eventually received mor-phine until death. Six of the patients receiving morphinedied on the ward. The median overall morphine dosagewas 6 mg/h, and the maximum dosage given at any timewas 30 mg/h. The dosage of opioids did not differstatistically among the 3 withdrawal groups at any timepoint. Furthermore, only 8 patients received a bolusinjection of opioids after therapy was withdrawn, asindicated in Table 4.
SedativesForty of the 50 patients (80%) mentioned above receivedsome kind of sedative until death. Nineteen patients re-ceived midazolam; it was stopped 4 hours before death in1 patient. Overall, patients received a median dosage of 6mg/h. The highest median dosage (8.5 mg/h) was ob-served in the MV withdrawal group in the last hour beforedeath. The dosages of midazolam did not differ signifi-cantly among the 3 withdrawal groups.
Fifteen patients received propofol, and none of thesepatients was transferred to the ward. In patients receiv-ing propofol, 7 had both MV and VAs withdrawn, 5 hadonly MV withdrawn, and in the remaining 3 patients,only VAs were withdrawn. Overall, the patients receiveda median dosage of 90 mg/h; 4 hours before death, they
Figure 1. Flowchart of patient survivaland withdrawal of mechanical ventilationand/or vasoactive agents. *Survival 1week after intensive care unit (ICU)discharge.
Table 1. Characteristics of 60 Patients Who DiedAfter Withdrawal of Mechanical Ventilation and/orVasoactive Agents
n (%) Median (IQR)Gender (male) 36 (60%)Age (y) 64 (52–73)Length of stay in ICU (d) 4 (1–10)APACHE II score 30 (25–34)SOFA score day 1 ICU 8 (7–11)SOFA score day before withdrawal 8 (7–12)Primary admission diagnosis ICU
Vasoactive agents withdrawn (no MV) 6 (10%)Received opioids until death 50 (83%)Received sedatives until death 40 (67%)Received neither opioids nor sedatives
until death10 (17%)
Died in ICU 50 (83%)Died on ward 10 (17%)
IQR � interquartile range; MV � mechanical ventilation; APACHE � AcutePhysiology and Chronic Health Evaluation; SOFA � Sequential Organ FailureAssessment; ICU � intensive care unit.
received 134 mg/h, and 1 hour before death, theyreceived 160 mg/h. Patients in whom only MV waswithdrawn received significantly more propofol 4 hours
before death and 1 hour before death than the other 2groups (323 mg/h vs 100 and 71 mg/h, P � 0.03; and 495mg/h vs 160 and 71 mg/h, P � 0.04, respectively).
Table 2. Time Until Death in 3 Different Groups After Withdrawal of Life-Sustaining Treatment
Mechanical ventilation and/orvasoactive support withdrawn n
ICU � intensive care unit.a Difference in time until death with Mann-Whitney U test for the 3 withdrawal categories in all patients, ICU patients, and ward patients.
Table 3. Use of Opioids and Sedatives Before and After Withdrawal of Mechanical Ventilation and/orVasoactive Support
Medication in total and per withdrawalgroups na
Cumulative quantity untildeath/hours from
withdrawal until deathDosage maximum 4 h before
deathDosage maximum 1 h before
death
Median IQR Range Median IQR Range Median IQR RangeFentanyl (�g), total 35 88 52–104 20–500 100 60–169 20–500 100 86–223 20–500
Withdrawal of mechanical ventilation andvasoactive support
Withdrawal of mechanical ventilation 3 1.3 — 0.3–1.8 1.4 — 0.3–2.7 1.8 — 0.3–3.2Withdrawal of vasoactive support — — — —P valueb 0.83 0.83 0.8
Drugs were administered by syringe pump.IQR � interquartile range; range � minimum–maximum dosages.a n � 50; 10 patients received no opioids or sedatives.b The differences in dosages among the 3 withdrawal groups were compared using the Kruskal-Wallis test.
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In the MV withdrawal group, 34 of 54 patients (63%)received sedatives in the last hours of their lives: 16 (27%)received midazolam (median, 10 mg/h), 12 (22%) propofol(median, 160 mg/h), and 6 (11%) lorazepam (2.0 mg/h).Sedatives were also administered to all patients in whomonly VAs were withdrawn; 3 received midazolam, whereas3 received propofol.
Only 6 patients received lorazepam, and none of thesepatients was transferred to the ward. The median overalldosage of lorazepam was 1 mg/h, and the maximummedian dosage was 1.7 mg/h 1 hour before death. Mostpatients were sedated by continuous IV syringe pumpinfusion. After withdrawal of treatment, only 3 patientsreceived bolus injections of a sedative (midazolam wasused 3 times, with a median of 5 mg/bolus).
Twenty (33%) of the patients who died after withdrawalof therapy did not receive any sedative.
DISCUSSIONIn our series, life-sustaining therapy was withdrawn in 13%of all ICU admissions. This is higher than reported instudies from other countries, in which withdrawal oftherapy accounts for only 1% to 8% of all ICU admis-sions.17–20 However, our study results are closer to findingsfrom the Ethicus study7 (9.8%), the report of Vincent et al.21
from Belgium (9%), and the results from the cohort surveyin the United Kingdom (UK),6 where a maximum with-drawal percentage of 9.9% was reported. Notably, the UKsurvey showed a remarkably high level of interhospitaldifference in the incidence of death as a result of with-drawal of treatment, which varied from 1.7% to 96%.6
Therefore, our results will probably not be representative ofDutch ICUs in general.
The incidence of MV withdrawal with or without VAs inour study was also higher than in other studies, whichreport that MV withdrawals occur in 4% to 39% of all ICUdeaths.17,19,20,22 In our study, only 7% of patients died afterwithdrawal of only VAs, which is lower than reported inother studies, in which 9% to 59% of patients died afterwithdrawal of VAs.17–19,22,23 These differences may beexplained by the fact that, in contrast to what is reported byKeenan et al.,24 we did not use a fixed order for withdraw-ing the different elements of supportive therapy. As can bederived from Table 2, VAs and MV are often withdrawntogether. In addition to this, there is generally only a smallgroup of incurably ill patients in the ICU who are VAdependent but not MV dependent. These facts togetherexplain our low incidence of VA withdrawal alone.
Some readers will conclude that our high percentage ofwithdrawal is not attributable to the severity of disease butrather that withdrawing life-sustaining therapy might bemore accepted in the Netherlands than in the UK and someother Northern European countries.7 Another, more likelyexplanation for these data is the high percentage of acutecatastrophic neurological diseases in our series. We hy-pothesize that ICUs that do not admit patients with severeneurological diseases will probably have lower rates oftreatment withdrawal. Only one study has reported a com-parably high number of acute neurological patients (51%),resulting in a death percentage due to withdrawal of treat-ment comparable to that in our study (11%), thus supportingour hypothesis.17 Furthermore, our patients seemed to bemore severely ill compared with patients from other studies.In our study, the median APACHE II score was 30, versus 24or 25 reported by other studies.19,24 It is reasonable to assumethat patients with high APACHE scores would be less likelyto respond to therapy; as a logical result, treatment waswithdrawn more often in our group.
The decision to withdraw treatment in our ICU isalways made by the medical staff and is based on multi-disciplinary team discussions. It is not a joint decision bystaff and the relatives of the patients, as is mentioned andsuggested in other publications.25,26 This approach is sup-ported by Dutch law, which generally places medical profes-sionalism above the rights and wishes of patients or proxies.
No special selection is made for what therapy to with-draw or in which order. We prefer to withdraw all life-sustaining treatment at the same time to demonstrate to thefamily that the decision is final.
Although the relatives of the patient do not activelyparticipate in the decision-making process itself, they areadequately informed in a timely and comprehensive manner,and special wishes are always taken into consideration. Inaddition, when desired or necessary, one of our religiousadvisers is always consulted. The exclusion of the family fromthe decision-making process is deliberate, to prevent thedevelopment of unnecessary guilt, stress, or even posttrau-matic stress disorder, as described by Azoulay et al.27 Theirstudy shows that active participation in the decision-makingprocess results in a higher level of guilt and stress, and that thestress level becomes even higher when the family believes thatthey are not adequately informed. Therefore, we focus onproviding adequate information to the family and not onengaging them in the decision-making process.
The short survival time in our study is comparable to theresults described by Keenan et al.24 and Chan et al.12 They
Table 4. Administration of Opioids and Sedatives, by Bolus Injection, in Patients Before and AfterWithdrawal of Mechanical Ventilation
Doses before withdrawalduring treatment
Dose maximum 4 h beforedeath
Dose maximum 1 h beforedeath
Dose after withdrawalof MV
n Median IQR n Median IQR n Median IQR n Median IQRFentanyl (�g/h) 4 100 63–213 4 100 63–123 2 175 100–250 1 50 —Morphine (mg/h) 8 7.5 5–10 4 8 5–25 3 10 5–30 7 10 5–10Midazolam (mg/h) 4 4 1–9 3 5 1–10 2 8 5–10 3 5 1–10Propofol (mg/h) 1 80 — 1 80 — 0 — — 0 — —Lorazepam (mg/h) 1 0.3 — 1 0.3 — 1 0.3 — 0 — —
show, as did our own findings, that most patients who aredependent on any kind of support die within 1 hour ofwithdrawal of therapy. This indicates that these patients,because of the severity of their diseases, as reflected byhigh APACHE scores, were highly dependent on thesetherapies.
Because family satisfaction with the process of withdraw-ing MV seems to be higher when the patient is tracheallyextubated, the endotracheal tube is removed in almost allpatients when MV is withdrawn in our ICU, even if this maybe associated with shorter survival.3 Our procedure is differ-ent from other studies showing that extubation is the leastused procedure in the withdrawal of life-sustaining treatment.It may be the fear of unwanted symptoms, such as acutestridor and death rattle, which keeps many intensive carespecialists from implementing this procedure.7,17,28
Most ICU specialists and fellows in our ICU are awarethat opioids are not to be used as a sedative and that theadministration of (increasing doses of) opioids does notnecessarily hasten death.12–15 Fentanyl is avoided for thetreatment of breathlessness in cachectic patients or inpatients with muscle weakness (e.g., patients with amyo-trophic lateral sclerosis).29 Specific doses of opioids andsedatives are less important than titration to achieve thedesired effect. Therefore, no fixed limits are applied todosages in our ICU. However, doses are preferably notincreased without titration or in the absence of demon-strable signs of discomfort or distress. Although the major-ity of patients did receive opioids until the time of death,the dosages used were lower than those reported by otherauthors and are, therefore, not outside the boundaries ofthe clinical practice described by others.12,14,24,30,31 How-ever, the differences in the dosages could be explained bymultiple other factors, many of which are not addressed inthe different studies to which we are referring. For ex-ample, the level of pain the patient is expected to experi-ence and the duration of morphine treatment before thedecision is made for withdrawal may have influenced theamount of medication needed.
The fact that morphine and fentanyl were discontinuedin some cases in our study suggests that our opioid dosageswere not increased in the absence of demonstrable signs ofdiscomfort or distress, but were used for comfort care onlyand certainly not with the intention to hasten death.Although this seems to be a legitimate and logical conclu-sion, we are, nevertheless, aware of the thin line betweeninitial intention and final result in the process of withdraw-ing treatment and the treatment of unwanted symptoms, asdescribed by Sprung et al.11 The observation that somepatients in our study who died after withdrawal of therapydid not receive opioids is explained by the high percentageof patients with primary catastrophic cerebral damage,who were deeply comatose and showed no signs of suffer-ing during the process of dying.
Sedatives are used for end-of-life care in our ICU toprevent and treat terminal restlessness and delirium, aswell as to increase the overall comfort of the patient duringdying. The most often used medications are midazolamand propofol. Lorazepam is a known independent riskfactor for delirium32; thus, the use of this drug is avoided asmuch as possible in end-of-life care, or only low doses are
used. This is reflected in the small percentage of patientswho received lorazepam in our study.
In the ICU setting, propofol is increased before death toquantities appropriate for palliative purposes, when neces-sary.33,34 The sedative doses in this study were not in-creased outside the boundaries of intentional palliativepractice and are lower than those reported by oth-ers.12,14,24,30,31 The fact that one-third of the patients did notreceive any sedative can again be explained by the highpercentage of deeply comatose patients with primary cat-astrophic cerebral damage. Indeed, 16 of the 27 patientswho were admitted for acute neurological diseases did notreceive continuous sedation.
Study LimitationsThis study has certain limitations that should be consideredwhen interpreting the data. In other international studies,in contrast to this study, no clear distinction is made in thedifferent life-sustaining treatments that are withdrawn. Inthese series, all life-sustaining treatment was withdrawn in2.8%, 9.9%, and 10.4% of all ICU admissions, withoutmaking any subclassification as to the type of life-sustaining treatment used and withdrawn.6,7,35
For this study, we used different sources of information.In the ICU, we used electronic patient files. Regrettably,time registration is not always accurate in these files,because the registration of vital signs is sometimes turnedoff to prevent unwanted alarms, for the sake of respect,when a patient is dying. Therefore, the exact time of deathcannot always be found in the electronic medical record.For this reason, some of the recorded times might not havebeen fully accurate; thus, corrections were made with thehelp of the paper files. In our study, we only studiedpatients in one closed-format academic ICU. As a result,our findings may not be applicable to other Dutch (aca-demic) ICUs or ICUs in other countries.
In addition, according to the reports in the patient files,most families seemed satisfied with the quality of commu-nication and the implementation of the procedures, andthere was a low incidence of conflicts regarding with-drawal of treatment issues. However, there was unfortu-nately no standardized and validated method, such as theFamily Satisfaction-ICU, available in the Netherlands tomeasure family and/or nurse/doctor satisfaction in theICU during the study period.36 In this study, we did notfocus on the possible relationship between individual dos-ages of opioids and sedatives and the time until death.
Finally, seasonal influences (e.g., the high percentage ofsevere brain injury due to traffic incidents in the winter)cannot be excluded, because we only gathered informationfor the period between October and February.
CONCLUSIONSMV and/or VAs are withdrawn in the majority of patientswho die in the ICU or who die shortly after discharge fromthe ICU. When these treatments are withdrawn, mostpatients die within 1 hour, reflecting the severity of theunderlying illness, as expressed by the high SOFA andAPACHE scores. Eighty percent of patients who died in theICU after withdrawal of life-sustaining treatment received
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opioids, and 67% received sedatives until they died. Fen-tanyl was the most frequently used opioid, and midazolamwas the most frequently used sedative. Opioids and seda-tives were used in normal doses up to the optimal titrationfor relief of symptoms. This study suggests that in our ICU,after withdrawal of MV and VAs, opioids and sedatives areused in generally accepted dosages, which are comparableto the dosages reported in other studies. This is in contrastwith what is often suggested about Dutch ICU end-of-lifepractices. Further qualitative and quantitative research isneeded to better describe end-of-life care in Dutch ICUs,thereby facilitating improvements in quality of care in thenear future.
ACKNOWLEDGMENTSWe thank Mrs. M. M. Dik and Mrs. C. Turnbull for theiroriginal input and their efforts in editing the manuscript.
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