Intensive Care and the End of Life

Published on 13/02/2015 by admin

Filed under Cardiothoracic Surgery

Last modified 13/02/2015

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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 Some treatments may be limited or withdrawn shortly before death because rapid inexorable decline should be evident to everyone, and such treatment limitations are usually readily accepted when the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.

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.