The Intensive care unit specialist: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine

et al. 2017

Two essential components of the profession of a medical doctor are the constant review of the patient's therapeutic project, and collaboration between healthcare professionals. The profession of intensive care unit (ICU) physician goes further in terms of responsibility, vis-à-vis the intensive treatments dispensed to the patients, and the physician's responsibilities towards the patient's family and the caregiving team, also bearing in mind that ICU care is costly in terms of human and financial resources. In this review, we address the profession of ICU physician from the perspective of the ethical questions that arise constantly, focusing on the timeframe of the reflection process. Firstly, admission to the ICU must be anticipated. The concept of advance care planning is a suitable tool for this, and in case of non-admission to the ICU, does not by any means constitute an abandonment of the patient, because palliative care can also be anticipated, with a view to avoiding suffering for the patient and their family. Next, during an ICU stay, while the technical aspects undoubtedly characterise the ICU best at the start of the patient's stay, the process of reflection rapidly becomes preponderant, and involves the analysis of often complex situations with a view to defining the level of therapeutic engagement and optimizing the care dispensed to the patient. Last, a further ethical issue concerns the decision to re-admit (or not) a patient to the ICU. This decision can be made, for example, in the framework of a systematic, formalised, structured, multidisciplinary meeting at the end of an ICU stay, using a similar procedure to that implemented for decisions relating to withholding or withdrawal of lifesustaining therapies. The profession of ICU physician is not simply a question of prolonging or sustaining life, but is also fraught with ethical questions about how best to employ their competences. In this regard, it is essential to foster interdisciplinary collaboration, and emphasise the need for ICU physicians to be involved in the development of therapeutic projects, particularly when the disease in question is likely to be complicated by acute situations that may require admission of the patient to the ICU.

Section: Introductionsupporting

confidence: 78%

What are the ethical dimensions in the profession of intensive care specialist?

Quenot¹,

Ecarnot²,

et al. 2017

“…In the literature, different approaches have been proposed for meeting these objectives, in particular advance care planning (ACP), ethics consultations, and palliative care consultations (1,(6)(7)(8)(9). Despite these various proposals, it is clear that the ICU physician must remain the preferred intermediary in the decision to admit a patient to the ICU (or not), as well as for decisions regarding possible limitation or withdrawal of life-sustaining therapy (4,10). There are several reasons that support this position (11).…”

Section: Introductionmentioning

confidence: 99%

What are the ethical questions raised by the integration of intensive care into advance care planning?

Quenot¹,

Ecarnot²,

et al. 2017

A major goal of intensive care units (ICUs) is to offer optimal management, but for many patients admitted to the ICU, they are unlikely to yield any lasting benefit. In this context, the ICU physician remains a key intermediary, particularly when a decision regarding possible limitation or withdrawal of lifesustaining therapy becomes necessary. The possibility of admission to the ICU, and the type of care the patient would like to receive there, should be integrated into the healthcare project in agreement with the patient, regardless of the stage of disease that the patient suffers from. These dispositions should be recorded in the patient's file, and should respect the progressive nature of both the disease itself, and the discussions necessary in such complex situations. The ICU physician can serve as a valuable consultant for the treating physician, in particular to guide patient choices when formalizing their healthcare preferences in the form of advance care planning (ACP) or advance directives (AD). Ideally, the best time to address this issue is before the patient's clinical situation deteriorates towards an acute emergency, and providing complete and transparent information to inform the patient's choices.

“…The decision to limit or withdraw life-support treatment is an integral part of the job of a physician working in the intensive care unit (ICU), and of the approach to care (1)(2)(3). However, this decision is influenced by a number of factors, such as resource availability and the surrounding environment, the use of intensive communication strategies (4,5), multidisciplinary care teams (6), institutional culture (7), cultural differences between countries (8), religious beliefs of the physicians (9), ICU family conferences (i.e., VALUES approach) (10), the presence or not of surrogate decision-makers (11), the use of ethics consultations (12) and ICU capacity strain (13).…”

Section: Introductionmentioning

confidence: 99%

What are the ethical aspects surrounding the collegial decisional process in limiting and withdrawing treatment in intensive care?

Quenot¹,

Ecarnot²,

et al. 2017

The decision to limit or withdraw life-support treatment is an integral part of the job of a physician working in the intensive care unit, and of the approach to care. However, this decision is influenced by a number of factors. It is widely accepted that a medical decision that will ultimate lead to end-of-life in the intensive care unit (ICU) must be shared between all those involved in the care process, and should give precedence to the patient's wishes (either directly expressed by the patient or in written form, such as advance directives), and taking into account the opinion of the patient's family, including the surrogate if the patient is no longer capable of expressing themselves. A number of questions still remain unanswered regarding how decisions to limit or withdraw treatment are taken in daily practice, especially when this decision can be anticipated. We discuss here the collegial procedure for decision-making, in particular in the context of recent French legislation on end-of-life issues. We describe how collegial decision-making procedures should be carried out, and what points are covered in shared discussions regarding decisions to limit or withdraw life-sustaining therapies.