End-of-Life Decision Making in the ICU

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A large proportion of deaths, particularly in the developed world, follows admission to an ICU. Therefore, end-of life decision making is an essential facet of critical care practice. For intensivists, managing death in the critically ill has become a key professional skill. They must be thoroughly familiar with the ethical framework that guides end-of-life decision making. Decisions should generally be made collaboratively by clinicians partnering with patients' families. Treatment choices should be crafted to meet specific, achievable goals. A rational, empathic approach to working with families should encourage appropriate, mutually satisfactory outcomes.

Section snippets

An approach to end-of-life decision making

The goal of end-of-life decision making is to meet patients' wishes and needs by choosing appropriate treatments. In Western society, these choices occur within an ethical framework dominated by key precepts: respect for patient autonomy, the physician's duty toward beneficence and nonmaleficence, and an obligation to ensure just distribution of resources.36

These precepts sometimes pose internal conflicts. For example, patients may refuse treatment or request care physicians believe

Rationing and triage

Rationing is defined as “the allocation of health care resources in the face of limited availability.”37 Triage refers to a specific system or plan to prioritize individual patients based on their underlying conditions (Box 1).38 Rationing and triage are uncommon in American ICUs, where it is unusual to refuse admission, even to patients who have end-stage illness.21, 39, 40 Limitations have long affected care in countries with fewer resources.41 The need to triage will likely become more

Futility

Few issues inspire more passion than medical futility.50, 51, 52, 53, 54, 55, 56, 57, 58 The definition of futility is hotly debated. However, any reasonable definition should recognize a condition as futile if no effective treatment exists. Futile care is inherently unethical, incurring cost and possible suffering without benefit.59 Identifying futility has critical implications for decision making. Many physicians and professional societies agree that physicians should not provide futile

Unconstrained decision making

Most end-of-life decisions are unconstrained by resource limitations or futility, and are restricted only by patient preference and practice standards. In North America (and, increasingly, elsewhere), respect for patient autonomy dominates decision making, empowering patients to choose among treatment options. In other places, paternalism often dominates, with physicians choosing treatments they think best for the patient, although this practice is becoming less frequent.23

Respect for autonomy

Family meetings

Family meetings precede most end-of-life decisions in North America. Well-conducted meetings promote appropriate decisions and family satisfaction and well-being.3, 4, 77, 110, 111 Meetings should occur shortly after ICU admission and not wait until decisions are urgent.4, 112 As with any medical procedure, successful meetings include several components, including a clear description of the medical facts, a discussion of goals and treatment options, and decision making (Box 3).3, 4, 77, 111, 113

Obstacles to successful family meetings

Several factors pose challenges to reaching consensus with families. Real or perceived conflict between families and physicians is common.17, 18 Physicians may be confounded by what they perceive to be a family's illogical thinking,63 which should be taken as a sign that important issues need to be addressed. Inadequate or delayed communication is a common problem, contributing to misconceptions about prognosis and treatment options.112, 127 Insufficient physician time to meet with families may

If conflict persists

One of the greatest challenges facing intensivists is how best to address impasses created when families request potentially futile or inappropriate treatments. Although it is widely held that physicians are not obligated to provide futile care,53, 55, 60 it is rarely necessary to forego therapy over a family's wishes.118 Conflict usually dissipates in response to empathic, comprehensive communication and patience.147

Impasses involving psychologic, spiritual, and social issues may require

Summary

A large proportion of deaths, particularly in the developed world, follows admission to an ICU. For intensivists, managing death in the critically ill has become a key professional skill. Intensivists must be thoroughly familiar with the ethical framework that guides end-of-life decision making. Moreover, they must become skilled in the nuanced practice of working closely with family members serving as surrogate decision makers. A combination of rational thinking, empathy, and patience will

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