Challenges in end-of-life care in the ICU

Abstract

The jurors identified numerous problems with end of life in the ICU including variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of health-care providers, the use of imprecise and insensitive terminology, and incomplete documentation in the medical records. The jury strongly recommends that research be conducted to improve end-of-life care. The jury advocates a "shared" approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honour decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the health-care team, to decide on the reasonableness of the planned action. In the event of conflict, the ICU team may agree to continue support for a predetermined time. Most conflicts can be resolved. If the conflict persists, however, an ethics consultation may be helpful. Nurses must be involved in the process. The patient must be assured of a pain-free death. The jury of the Consensus Conference subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double effect" should not detract from the primary aim to ensure comfort.

Availability of Advance Care Planning Documentation for Older Emergency Department Patients: A Cross-Sectional Study

“…Designating a HCPOA is potentially valuable, but only if this can accurately convey the patient's preferences under a variety of clinical circumstances and if the designee is available in an emergency. [33][34][35][36] Living wills also vary with regard to the amount of detail provided. We did not examine the quality or accuracy of designees and documents, only whether or not they were available in the EHR.…”

Brief review: Practice variation in end of life care in the ICU: implications for patients with severe brain injury

“…49 Outside of Canada there is a body of evidence to suggest that end of life care in the ICU falls short of these standards, leading to calls for better palliation. 50,51 The situation in Canada appears more encouraging with families reporting that most patients die in comfort in the ICU 17 and that the families themselves feel supported during the dying process. 37 However, inconsistencies in end of life care practices may affect where patients die, how they die, the quality of that death 52,53 and whether or not patients are considered for organ and tissue donation in the ICU.…”

Limitação de suporte de vida em três unidades de terapia intensiva pediátrica do sul do Brasil

“…The end of life of ICU patients is no longer an intimate moment shared only among family and friends; it has become a solitary moment surrounded by technology and, not uncommonly, pain. 1 Several studies have been published, especially in the USA, since 1990, that question the principle of life at any cost. 2,3 End-of-life decisions are now widely discussed, placing a high value on the respect for the patient, including a growing concern with maintaining dignity at the end of life and humanization of death.…”