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
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.
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.
