End-of-Life Issues in Intensive Care Units

Abstract

Critical care clinicians strive to reverse the disease process and are frequently faced with difficult end-of-life (EoL) situations, which include transitions from curative to palliative care, avoidance of disproportionate care, withholding or withdrawing therapy, responding to advance treatment directives, as well as requests for assistance in dying. This article presents a summary of the most common issues encountered by intensivists caring for patients around the end of their life. Topics explored are the practices around limitations of life-sustaining treatment, with specific mention to the thorny subject of assisted dying and euthanasia, as well as the difficulties encountered regarding the adoption of advance care directives in clinical practice and the importance of integrating palliative care in the everyday practice of critical-care physicians. The aim of this article is to enhance understanding around the complexity of EoL decisions, highlight the intricate cultural, religious, and social dimensions around death and dying, and identify areas of potential improvement for individual practice.

Palliative Care Principles and Anesthesiology Clinical Practice: Current Perspectives

“… 15 Data suggest that integration of palliative care in the ICU improves quality of life, caregiver burden and might lead to decreased hospital and ICU length of stay, although this last point is controversial. 16–19 …”

“… 18 , 43 There is considerable worldwide variability in decisions to withhold/withdraw life-sustaining treatments 44 which might be influenced by cultural, religious and social factors as well as by the ICUs ethical climate. 16 , 45 Even so, an intensivist should avoid disproportionate and non-beneficial treatments. Decisions surrounding end of life care should be made by the entire ICU team of clinicians, and not by a subset of members.…”

“…15 Data suggest that integration of palliative care in the ICU improves quality of life, caregiver burden and might lead to decreased hospital and ICU length of stay, although this last point is controversial. [16][17][18][19] There are two main models to provide palliative care in ICU. 5,16 The consultative model is based on the fixed presence of palliative care specialist physicians consulted by intensivists upon patients meeting triggers for initiation of palliative care.…”

“…[16][17][18][19] There are two main models to provide palliative care in ICU. 5,16 The consultative model is based on the fixed presence of palliative care specialist physicians consulted by intensivists upon patients meeting triggers for initiation of palliative care. 5,20 Even though the number of palliative care specialists is increasing, their availability is not sufficient to cover the raising need for palliative care in the ICU population.…”

“…41,[46][47][48] Patients admitted to ICU are usually not able to express their preferences about end of life care directly. 16 Therefore, intensivists have to acknowledge any advance directive and interact with patient's surrogate decision maker and family. During patient's stay in ICU, physicians are recommended to use routine interdisciplinary family conferences to receive directives, discuss goals, assess family needs, cultivate mutual trust and reduce conflicts between the treating clinicians and the family members.…”