A Quality Improvement Project to Improve Documentation and Awareness of Limitations of Life-Sustaining Therapies

PURPOSE: Poor documentation and understanding of the limitations of life-sustaining therapies upon admission to the pediatric intensive care unit (PICU) can result in moral distress for both providers and families. Limitations of life-sustaining treatments are often not documented and/or understood by members of the health care team.

METHODS: We performed a quality improvement initiative to improve the care teams' understanding and paper documentation of the limitations of life-sustaining therapies in the PICU of a quaternary children's hospital from January 2018 to March 2019. We implemented a series of plan-do-study-act cycles, including initiation of an updated rounding tool that included limitations of interventions, in-person and electronic information sessions, and implementation of a visual bedside tool to remind providers when limitations were present. Pre- and postintervention surveys were administered.

RESULTS: Nursing paper documentation of limitations of life-sustaining therapies increased sequentially from 0% to 88% during plan-do-study-act cycles. Creating a specific area to document limitations on the nursing sheet resulted in the most significant increase in documentation (36.6 points). Nurses reported that they "always" document limitations, which increased from 10% to 38%. The percentage of nurses who understood patients' intervention limitations increased from 28% to 33%.

CONCLUSIONS: Limitations of life-sustaining therapies in the PICU are nuanced and involve multiple stakeholders. Nursing education and designation of a section of intervention limitations in nursing daily goal paper documentation can increase comfort with therapeutic limitations in the PICU. Future studies should explore impacts on patient care and serve as a framework for the ultimate goal of improving documentation of care limitations and code status in the electronic medical record.