Dying Patients in the Intensive Care Unit: Forgoing Treatment, Maintaining Care

Abstract

End-of-life care of patients in the intensive care unit (ICU) often requires dramatic shifts in attitudes and interventions, from traditional intensive rescue care to intensive palliative care. The care of patients dying in ICUs raises both clinical and ethical difficulties. Because fewer ICU patients are able to make decisions about withdrawing treatment, careful attention must be paid to previously expressed preferences and surrogate input. Cultural and spiritual values of patients and families may differ markedly from those of clinicians. Although prognostic models are increasingly able to predict mortality rates for groups of ICU patients, their usefulness in guiding specific decisions to forego treatment has not been established. When a decision to forego treatment is made, the focus should be on specifying the patient's goals of care and assessing all treatments in light of these goals; interventions that do not contribute to the patient's goals should be discontinued. Symptoms accompanying withdrawal of life support can almost always be controlled with appropriate palliative measures. After ICU interventions are foregone, patient comfort must be the paramount objective. Whether in the ICU or elsewhere, hospitals have an ethical obligation to provide settings that offer dignified, compassionate, and skilled care.

Most critically ill patients are perceived to die in comfort during withdrawal of life support: a Canadian multicentre study

“…[6][7][8][9] These calls have been made in response to the frequency with which death in the ICU is preceded by withdrawal of life support [10][11][12][13][14][15][16] and due to ongoing concerns, particularly in the United States, about the discomfort of patients dying in hospital. 17,18 Recent media attention focused on death in the ICU in Canada 19,20 could be interpreted by the public to imply that the experience for Canadians dying in ICUs is generally poor, despite the lack of empirical Canadian data to support this contention.…”

O processo de morrer e a morte no enfoque dos profissionais de enfermagem de UTIs

“…A espiritualidade pode ser compreendida como uma dimensão da personalidade que habita e se desenvolve no mais íntimo do ser, identifica-se com o si mesmo, que se integra com os valores culturais em um sistema de crenças, símbolos, visão de mundo e sentido de vida pessoal. E essa dimensão espiritual expressa-se em idéias, sentimentos, atitudes e condutas (12) . …”

Withholding and Withdrawing Dialysis in the Intensive Care Unit

“…Dialysis discontinuation is probably one of the first things to occur whereas discontinuation of artificial feeding and hydration and mechanical ventilation are likely to be the last interventions withdrawn (49). A palliative care consultation should be considered to aid in pain and symptom management, hospice referral, and support of family adjustment to end-of-life care.…”