Making good death more accessible: end-of-life care in the intensive care unit

Abstract

Despite advances in critical care medicine, decisions and communications about withholding or withdrawing lifesustaining interventions are routine for intensive care unit (ICU) physicians who attend critically ill patients [1]. Nonetheless, the quality of the dying process and ICU physicians' comfort in discussing end-of-life issues with families vary not only across the globe but also within a region. In a large-scale study on the practices of ICU physicians in Asia who manage critically ill patients [2], respondents reportedly often withheld but seldom withdrew life-sustaining treatments at the end-of-life, although variations in attitudes and practice exist across countries and regions. Using the data from that study, Phua et al. [3] report in a recent article how regional economic status in particular has a significant impact on ICU physicians' attitudes regarding withholding or withdrawing life-sustaining interventions for end-of-life patients. Physicians in low-middle income countries were less likely to withhold and withdraw resource-intensive and invasive interventions (e.g. cardiopulmonary resuscitation, mechanical ventilation and vasopressors and inotropes, tracheostomy and haemodialysis), although they were more likely to forego less aggressive interventions (e.g. enteral nutrition, intravenous fluid therapy, oral suctioning). These physicians, who are more inclined to accede to families' requests to withdraw life-sustaining treatments on financial grounds, are nevertheless more agreeable to follow families' demands to continue these interventions, possibly out of their perceived legal risks associated with a lack of policies and ethical guidance on limiting and overriding family requests for non-beneficial treatments [3].The interesting, albeit somewhat counterintuitive, finding of physicians' relative comfort in foregoing less invasive interventions while continuing aggressive artificial life support in a family-driven environment begs the question of how well families understand these different interventions, and how information regarding these interventions is being communicated. While death in the ICU is common, less than half of the ICU physicians in the study [3]-40.6 % of those from high income countries and 46.3 % from low-middle income countries-feel comfortable in having end-of-life discussions with patients' families. Such discomfort highlights the possibility that even well-intended clinicians may miss valuable opportunities to address and clarify families' misunderstandings and concerns regarding goals of care at the end of life [4].While Phua et al. 's [3] regional focus may invite EastWest comparisons on cultural attitudes and decisionmaking processes regarding death and dying [5], culture is only meaningful when analysed and interpreted in particular local sites and contexts [6]. Socio-economic, legal, professional, religious, educational and technological factors intersect and frame not only families' expectations but also clinicians' contribution and responses to these expectation...

End-of-life perceptions among physicians in intensive care units managed by anesthesiologists in Germany: a survey about structure, current implementation and deficits

“…In Canada, a series of guidelines address withdrawal, distress and discontinuation [16]. There is a critical need to reframe EOL care planning, not prioritizing life extension over good death [17]. Thus, tools are already available to enable a shift from unsatisfactory Category 3 to sufficient Category 1.…”

“…Presently, between 10% and 20% of the population at large now die in the ICU underlining the importance of EOL care to everyday practice and training [25], being extended to EOL orders (Q41) for continuing care after death for relatives (Q43) (Additional file 10: Figure S10). Many clinicians and families equate withholding or withdrawing as giving up [17]. Communication and intervention withdrawal practice guidelines that highlight EOL care as part of, rather than separate from, critical care and education [28] are available and may be crucial in supporting ICU teams to help make good death more accessible [17].…”

“…Many clinicians and families equate withholding or withdrawing as giving up [17]. Communication and intervention withdrawal practice guidelines that highlight EOL care as part of, rather than separate from, critical care and education [28] are available and may be crucial in supporting ICU teams to help make good death more accessible [17]. …”

Palliative care in intensive care units: why, where, what, who, when, how

“…In the latest years, ICU admissions in the last month of life have been growing up to 30% [ 1 , 4 ]. When the organ dysfunction of critical illness does not respond to treatment, and the goals of care cannot be achieved anymore, or when life support becomes to be non proportional to expected prognosis, ICU physicians should provide an acceptable death [ 5 , 6 ]. When life-sustaining therapies are unable to meet the patient’s goals, or paradoxically may result to be more burdensome than beneficial, withdrawal and withholding of therapies is a commonplace among ICU physicians [ 7 ].…”

Revisiting the equity debate in COVID-19: ICU is no panacea

“…Ho and Tsai argue that, "In considering effective and efficient allocation of healthcare resources as well as physical and psychological harm that can be incurred in prolonging the dying process, there is a critical need to reframe end-of-life care planning in the ICU." 25 We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to minimising barriers to accessing culturally safe care in the following interlinked areas: palliative care, and communication and decision support and advanced care planning.…”