With the STOP icon the nursing personnel can only consult LSTL, and the corresponding treatment and care sheets contain the same icon with an associated special care plan.

Once level 1 has been established, and if considered opportune by the supervising physician, a sedoanalgesia protocol can be activated, with direct indication in the treatment sheet of the prescription of morphic chloride and midazolam boluses, together with morphic chloride in continuous infusion, with doses adjusted to the terminal patient age, weight and needs.

With these measures we believe it is possible to:

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  Avoid futile treatments, thereby lessening the suffering for the patients and their families, and the associated economical costs.

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  Provide pain relief and improvement of other symptoms in the end stages of life, based on treatments aimed at affording wellbeing and which can be started easily and quickly.

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  Obtain a clear and concise registry of the LSTL decisions in the clinical records.

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  Establish a reminder of patient inclusion in the LSTL protocol for re-evaluation and follow-up.

We developed this tool during a period of one year, after which it was presented in a general session on 12 February 2011, after being accepted by both the Ethics Committee and the Management Board of our center. Application started 24h later, and after three months the number of patients with activated LSTL status reached 120 (3 patients/day). Of these, 54.5% were males, and the median age was 82 years. The Departments from which LSTL activation originated were Internal Medicine (43.8% of the cases), Oncology (14%), Emergencies (13.2%), ICU (12.4%), Cardiology (4%), Hematology, Pneumology and Neurology (2.5%), Traumatology (1.7%), and General Surgery, Pediatrics, Anesthesiology and Nephrology (0.8%).

The reasons or considerations for establishing LSTL were:

• Quality of life (24%)

• Life expectancy<6 months/terminal (21.5%)

• Previous functional limitation (19%)

• Futility (20.7%)

• Age (8.3%)

• Pre-expressed wish (4.1%)

The levels activated were level 1 (14% of the cases), level 2 (43%) and level 3 (43%). In the latter, the restricted life support measures were:

• 1.

  Cardiopulmonary resuscitation: 40%

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  Electrical cardioversion: 29%

• 3.

  Orotracheal intubation and mechanical ventilation: 40%

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  Noninvasive ventilation: 0%

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  Dialysis: 27%

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  Vasoactive drugs: 27%

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  Blood product transfusions: 0%

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  Parenteral nutrition (TPN): 9%

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  Enteral nutrition: 11%

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  Nasogastric tube (NGT): 7%

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  Central catheter: 12%

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  Surgical interventions: 27%

A change in LSTL level was decided in 10.8% of the cases. The change was from level 1 to level 2 in two cases, from level 2 to level 1 in 9 cases, from level 3 to level 2 in one case, and from level 3 to level 1 in one patient. In no case was LSTL definitively suspended (at discharge). A total of 23.3% of the patients finally presented LSTL level 1, with activation of the available sedoanalgesia protocol in of them.

The family was informed in 93.4% of the cases. In the remaining cases the family either could not be contacted or the patient had no family. The patient was only informed in 18.2% of the cases, since most subjects presented prior dementia, diminished consciousness, etc.

A total of 57 patients (47%) died during admission in which LSTL was activated. Twenty-four patients (20%) were referred to chronic care centers.

In 26% of the patients LSTL was activated in the first 24h after admission. The mean time from hospital admission to LSTL was 6.7 days, while the mean time from LSTL activation to discharge/death was 8.2 days. Six percent of the patients died on the day of LSTL activation. In three cases LSTL was activated from the hospital wards.

Three months after application of the protocol, the generalized opinion among the healthcare professionals was that the tool is useful, as evidenced by its routine use, facilitating the daily work of both the physicians (fundamentally while on duty, when the physician in charge of the patient cannot be consulted) and the nurses–who appreciate knowing the stage in the patient course, the measures to be taken and restricted, and the possibility of implementing a special care plan with which to help and support both the patients and their families.

The main problem reported has been correct differentiation between LSTL levels 2 and 3. Level 3 was initially created to limit only certain life support measures, though without specifying whether the patient could be admitted to the ICU or not. On the other hand, some Departments asked us to expand these measures to include other less aggressive measures, but which cause patient discomfort. We mistakenly decided to incorporate them to level 3, generating confusion in distinguishing patients amenable to conservative medical treatment (level 2) from those at level 2 who in addition to the more aggressive measures also received limitations of other therapies including nasogastric tubes, total parenteral nutrition, etc.

Two modifications are presently pending:

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  Measures such as nasogastric tubes and central catheters, enteral and parenteral nutrition, and blood product transfusions would move to level 2, as a result of which only the more aggressive measures would remain at level 3.

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  The LSTL “Admission to the ICU” would be moved to level 3.

We therefore consider that we can and must modify this tool, establishing clear definitions allowing unification of the reasons and levels of LSTL. On the other hand, we consider it necessary to further promote reminders of LSTL with a view to establishing it as a routine practice. In this context, we always must remember that our efforts do not end with LSTL activation, and that multiple measures for patient wellbeing, pain relief, family accompaniment, etc., remain to be applied.

The authors declare no conflicts of interest.