Intensive Care and the End of Life

Published on 13/02/2015 by admin

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Chapter 39 Intensive Care and the End of Life

Death remains a common event in the intensive care unit (ICU) and there are often shortcomings in the endof-life care that dying patients and their families receive.¹ Any critically ill patient may die, although the extent of this risk varies enormously among individuals. Recognizing and accepting the possibility that a patient may die should prompt every involved clinician to ensure that every patient and every patient’s family receive good end-of-life care—from the time of ICU admission and while potentially lifesaving therapies are being applied.²

Although the beneficial components of good end-of-life care in the ICU have yet to be well defined, commonly stressed themes include good communication, control of distressing symptoms, continuity of care, attention to emotional and spiritual needs, “evident compassion,” and ensuring family access to the dying patient.

OVERVIEW OF CLINICAL PRACTICE

Because of inherent uncertainty about an individual patient’s outcome, patients are usually treated aggressively at the beginning of their ICU stays. Most cardiac surgery patients make rapid progress and leave the ICU alive within a few days. However, approximately 2% of them deteriorate and die despite continued intensive therapies,³ whereas a somewhat larger group develop multiple organ failure or signs of severe brain damage. Brain death is rare after cardiac surgery and usually occurs in the context of a large cerebral hemorrhage or hemispheric infarct.

Patients who deteriorate rapidly despite treatment (e.g., with cardiogenic shock after myocardial infarction or progressive intracranial hypertension resulting from intracranial hematoma or cerebral infarction) very rarely receive cardiopulmonary resuscitation. Some treatments may be limited or withdrawn shortly before death because rapid inexorable decline should be evident to everyone, and such treatment limitations are usually readily accepted when the nature of the illness is carefully explained to the family. Decision making about limitation or withdrawal of intensive therapies is more problematic in patients in whom persistent multiple organ failure develops and in those who do not become brain dead but have very severe brain damage, usually caused by hypoxic-ischemic insults or stroke.

Prognosis and Decision Making

In a patient in whom multiple organ failure is persistent and in whom decline is slow but inexorable, the situation becomes increasingly obvious over time. A period of observation within the context of an agreed-upon plan not to escalate therapy during continuing clinical deterioration can help to clarify the overall course of the patient’s illness.⁴ The concept of an illness trajectory² may help the treating team and the patient’s family to focus on whether the balance between attempted reversal of the multiple organ failure and providing comfort measures is reasonable for the individual patient.

RECOMMENDED CLINICAL PRACTICE

It is not uncommon for staff in ICUs to overly attend to an objective of cure or recovery. If the objective of comfort and relief of suffering is simultaneously and explicitly attended to from the moment of admission, there are far fewer difficulties for all concerned in the processes of withholding or withdrawing certain treatments should such actions become appropriate. Attending to the objectives of both cure and comfort at all times acknowledges that the relative priority of these objectives may shift during the course of the patient’s illness.

Failing to attend to comfort and focusing only on cure can potentially impede the acknowledgment by doctors and by the patient and family of the increasingly evident failure of the cure objective. Many other aspects of care (including attention to the psychological and spiritual needs of the patient) are often delayed in dying patients until a short time before death, when it becomes difficult if not impossible to meet these needs. The earlier involvement of others who may assist the seriously ill patient and the family (e.g., social workers, palliative care specialists, chaplains, and others) is facilitated by not defining a time before which cure is the only objective and after which comfort is the main objective.

Language

In discussions with patients and families, doctors should not use technical or medical language but instead should communicate in nonmedical terms used in everyday speech.⁵ Some words used in the medical literature and by doctors in clinical conversation are commonly insensitive and imprecise and are used without apparent awareness of their emotional overlay. If such words are part of doctors’ common speech they will inevitably be heard by dying patients and their families and will thereby affect their perceptions of and the course and nature of the interpersonal transactions that take place. Some phrases are inherently insensitive (e.g., “withdrawal of care,” “futility,” and “terminal care”) or imprecise (e.g., “passive euthanasia”), or they have emotional overtones arising from their meaning in common usage (e.g., “paternalism,” “autonomy,” “nutrition,” and “hydration”).

The term “withdrawal of care” is still widely used,⁶^–⁸ although the awful implication of the literal meaning of the phrase was pointed out long ago.⁹ It is important to make clear to the patient and the family that care will not be withdrawn, only some treatments.^10,¹¹

The term “futility” is also problematic in communications with a patient and family because of its meaning in common parlance of having no useful result, no purpose, or no importance. When used in the context of end-of-life care it can easily come to imply that because continuing to treat the patient is futile or has “a lack of worth,” this “worthlessness” is a characteristic of the patient or perhaps describes the way in which the doctor views the patient. Second, the meaning of “futility” in this context is highly subjective; it could be argued that any therapy that prolongs life at any cost has some intrinsic utility and, indeed, some patients and families do argue for this attitude. Finally, despite its apparently definitive nature, it is not possible for the word to be given a prospective operational definition, so it is often used imprecisely.

Grenvik introduced into intensive care medicine the concept “terminal weaning” to describe an orderly process of withdrawal of intensive therapies irrespective of subsequent physiologic deterioration.¹² However, a better descriptive term that has a weaker implication of expected death should be used.¹³ Withdrawal of intensive therapies is not always followed by the immediate death of the patient, and a few patients will survive long term. Clearly, the process is not always terminal, nor is it the doctor’s intent that it be so. Similar difficulties pertain to the use of the phrase “terminal care” to describe the process of care during and after withdrawal of therapies. The term “comfort care” is preferable to “palliative care” in this situation because comfort is a familiar and unambiguous aspect of everyday experience, whereas the word “palliative” is a technical and medical term.