(379) Implementation of a Withdrawal of Life-Sustaining Therapies Checklist Huddle

Introduction:

Introduction: Approximately 80% of pediatric deaths occur in the pediatric intensive care unit (PICU), with a significant proportion being after withdrawal of life sustaining therapies (WOLST).1–3 There are few published guidelines for how to prepare for and proceed with WOLST, and there is significant practice variation within intensive care units, nationally, and globally.4–6 Previously, a needs assessment survey at this institution identified that 44% of PICU nurses felt “fair” or “poor” regarding comfort with speaking to families about end-of-life care and after death. Consequently, a quality improvement project was developed to review preparations for withdrawal and address any concerns with the care team prior to proceeding.

Methods: A checklist to guide a WOLST huddle was developed through literature review and multidisciplinary discussion at Nationwide Children’s Hospital (NCH). This checklist includes critical tasks to be completed by the team in preparation for WOLST, including review of signs and symptoms of dying with the patient’s family and bedside staff, the symptom management plan, expected order of events, and completed multidisciplinary communication. An electronic medical record (EMR) documentation template was created to document the checklist huddle, and information regarding the project was disseminated to the PICU faculty and staff. The outcome measure is huddles completed per withdrawal (goal 40%), and the process measure is huddles appropriately documented per huddles completed (goal 75%).

Results: From February 2024 to June 2024, 14 of the 18 deaths (78%) in the NCH PICU occurred after WOLST. A huddle was completed prior to 12 (86%) of these withdrawals. The huddles were documented in the EMR using the appropriate checklist template for 9 (75%) of the completed huddles. There were no reports of nursing or provider dissatisfaction with the WOLST huddle process.

Conclusions: The goals for huddle completion and documentation were met within the first PDSA cycle. The second PDSA cycle aims to improve the variability in documentation and continued improvement in huddle compliance. Additionally, we plan to collect qualitative data from the PICU staff to assess the impact of and further refine the huddle process.