Withdrawal of Intensive Care Treatment at Home – ‘a Good Death’

Abstract

A patient with end-stage congestive cardiac failure and acute renal failure was admitted to the intensive care unit for inotropic support. Following no improvement with treatment, the focus of care shifted to the patient's comfort, palliative care and family support. She wished to die at home and therefore all efforts were made to fulfil her desire. This was achieved and she was discharged from the intensive care unit on inotropes and allowed to die in the comfort of her own home, with the withdrawal of treatment occurring only when the patient was ready.

Uncovering the decision‐making work of transferring dying patients home from critical care units: An integrative review

“…Transfer decision‐making processes also involved multi‐disciplinary HCPs. In many cases, hospice (Lusardi et al., ; Poucher, ) or palliative care clinicians (Campbell, ; Clinch & Le, ; Crighton et al., ; Kumar, Obuch, & Vyakarnam, ; Tellett & Davis, ) were involved in the transfer discussion or arrangement. Other people involved included hospital administrators, transport personnel, coroners, bereavement teams and social workers (Battle et al., ; Clinch & Le, ; Creechan, ; Kumar et al., ; Mann et al., ; Ryder‐Lewis, ).…”

“…In practice, transfer home was largely carried out by critical care nurses (Battle et al., ; Boussarsar & Bouchoucha, ; Coombs et al., ; Huang et al., ; Kumar et al., ; Mann et al., ; Ryder‐Lewis, ; Tellett & Davis, ). In one case the initial transfer home was accompanied by a doctor (Battle et al., ).…”

A national survey exploring views and experience of health professionals about transferring patients from critical care home to die

“…The study investigated in a large sample health professionals' experience and views of transfer of critically ill patients home to die, as well as the associated characteristics of patients. Whilst this practice has been previously reported to be an uncommon event in critical care, [6][7][8][9][10][11][12][13][14][15][16] in excess of a third of respondents to this survey had been involved in transferring between 1 -5 patients home over the past three years, with a further 16% of respondents having been involved in discussions about transfer home. In addition, health professionals' views tended to be positive and a majority of them would consider taking a patient home to die with complex care needs, as long as they were not unstable or ventilated via an endotracheal tube.…”

“…inotropes) as less suitable for transfer home; respondents were divided in opinion about patients who were ventilated via a tracheostomy. Clinical instability has been described in the international literature as being a key limitation in relation to transfer home, 9 although there are examples of where intubated and inotropic dependent patients 11 are transferred home and then extubation and terminal weaning then occurs in the home environment. 8,14 However, for instance in a study describing this service in a single institution the authors had made the a-priori decision to exclude patients who were supported on ventilation via an endotracheal tube.…”

“…Published work has described the overwhelmingly positive views of this practice of those health professionals who have facilitated such a transfer. [9][10][11][12][13] However, these data are limited to case reports and editorials, and thus unlikely to be representative of the views of critical care health professionals more generally, including those who have never been involved in such a transfer.…”