End‐of‐life care in the intensive care unit

Abstract

The transition from active, invasive interventions to comfort care for critical care patients is often fraught with misunderstandings, conflict and moral distress. The most common issues that arise are ethical dilemmas around the equivalence of withholding and withdrawing life-sustaining treatment; the doctrine of double effect; the balance between paternalism and shared decision-making; legal challenges around best-interest decisions for patients that lack capacity; conflict resolution; and practical issues during the limitation of treatment. The aim of this article is to address commonly posed questions on these aspects of end-of-life care in the intensive care unit, using best available evidence, and provide practical guidance to critical care clinicians in the UK. With the help of case vignettes, we clarify the disassociation of withdrawing and/or withholding treatment from euthanasia; offer practical suggestions for the use of sedation and analgesia around the end of life, dissipating concerns about hastening death; and advocate for the inclusion of family in decision-making, when the patient does not have capacity. We propose a step-escalation approach in cases of family conflict and advocate for incorporation of communication skills during medical and nursing training.

Efficacy of Advance Care Planning Support by Decision Aid in Intensive Care Patients: A Pilot Randomized Trial

“…Details of life-saving treatment in the ICU may not be immediately understood by providing speci c information while the patient is being treated [29]. In the ICU, patients and their families often must make urgent decisions [30]. Differences in the perceptions of treatment understanding among medical providers, patients, and family members lead to problems after treatment [31].…”

Dying to be better: Outlining the growing benefits of palliative care training in intensive care medicine

“…Robust support systems, both personal and departmental, are vital to managing complex ethical scenarios when practising modern critical care; formal education, or clinical experience of this, could be gained through learning from our palliative care colleagues. 28 One example of this is in the training of critical care nurses to become 'palliative care champions' by palliative care colleagues. This interdisciplinary model has been shown to improve regularity of communication with patient relatives, regularly update staff on modern palliative care practices, and establish peer support mechanisms within the department.…”

“…Robust support systems, both personal and departmental, are vital to managing complex ethical scenarios when practising modern critical care; formal education, or clinical experience of this, could be gained through learning from our palliative care colleagues. 28…”

Intensive care 2.0

“…Although we often ``rage against the dying of the light´´, death is sadly familiar in the ICU. We will hear about this opposite end of the spectrum from new life, end-of-life care with Tanaka Gutiez et al [15]. and make-up of special issues like this is something all journals should foster.…”

“…We will hear about this opposite end of the spectrum from new life, end‐of‐life care with Tanaka Gutiez et al. [15].…”