It is common for patients to have an expected death in an ICU. The final review in the Critical Care series covers issues related to the end of life in the absence of discordance between the patient’s family and caregivers.
The traditional goals of intensive care are to reduce the morbidity and mortality associated with critical illness, maintain organ function, and restore health. Despite technological advances, death in the intensive care unit (ICU) remains commonplace.
• According to the authors, what are the principles of “dying with dignity?”
The definition of “dying with dignity” recognizes the intrinsic,unconditional quality of human worth but also external qualities of physical comfort, autonomy, meaningfulness, preparedness, and interpersonal connection. Respect should be fostered by being mindful of the “ABCDs” of dignity-conserving care (attitudes, behaviors, compassion, and dialogue).
Table 1. Examples of the ABCDs of Dignity-Conserving Care.
• How is palliative care defined by the World Health Organization?
The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Palliative care, which is essential regardless of whether a medical condition is acute or chronic and whether it is in an early or late stage, can also extend beyond the patient’s death to bereaved family members.
Figure 1. Curative and Palliative Approaches to Care throughout a Critical Illness.
Morning Report Questions
Q: How is family satisfaction in the ICU setting impacted by communication with clinicians?
A: Clear, candid communication is a determinant of family satisfaction with end-of-life care. Notably, measures of family satisfaction with respect to communication are higher among family members of patients who die in the ICU than among those of ICU patients who survive, perhaps reflecting the intensity of communication and the accompanying respect and compassion shown by clinicians for the families of dying patients. The power of effective communication also includes the power of silence. Family satisfaction with meetings about end-of-life care in the ICU is greater when physicians talk less and listen more.
Q: How many physicians in the ICU feel comfortable making recommendations to forgo the use of life-supporting technology, and how many report consistently doing so?
A: Physicians in the ICU sometimes make recommendations to forgo the use of life-support technology. In one study involving surrogates of 169 critically ill patients, 56% preferred to receive a physician’s recommendation on the use of life support, 42% preferred not to receive such a recommendation, and 2% stated that either approach was acceptable. A recent survey of ICU physicians showed that although more than 90% were comfortable making such recommendations and viewed them as appropriate, only 20% reported always providing recommendations to surrogates, and 10% reported rarely or never doing so. In this study, delivering such recommendations was associated with perceptions about the surrogate’s desire for, and agreement with, the physician’s recommendations. Other potential influences are uncertainty, personal values, and litigation concerns.