To save the lives of critically ill patients, intensivists utilize sophisticated technologies to support vital organs until treatments reverse underlying medical conditions. Most patients recover from the acute event, a few die rapidly, and the remainder fail to improve and remain dependent on life-sustaining treatments. In this last group, the chance of recovery changes from one day to the next, and questions often arise about the appropriateness of continuing life support, especially mechanical ventilation.1
Over the last half century, health care professionals in intensive care units (ICUs) have been forced to make decisions for patients who remain dependent on mechanical ventilation with death in the short term as the only possible outcome.2 In these patients, continued treatment in the hope of cure is rarely the best option.3 Mechanical ventilation may be prolonged beyond the point of beneficence, robbing patients of their dignity and families of their right to honest prognostic information and an opportunity to prepare for bereavement. The best option here is a decision to forego life-sustaining treatment.
Because respiratory failure, shock, and coma are common reasons for ICU admission, mechanical ventilation is the most widely used life-sustaining treatment in the ICU.4 Thus, mechanical ventilation is also the most common target of a decision to forego life-sustaining treatment.5–10 Although most patients are successfully weaned off the ventilator, a few die while on the ventilator or immediately after weaning.11 Ideally, a decision to forego life-sustaining treatment, which consists of moving from curative care to comfort care, should be based on the patient’s wishes.12,13 When the issue of comfort care arises, however, fewer than 5% of patients are able to participate in decisions, and knowledge of their preferences is usually unavailable.14,15 Therefore, concern that curative care may be harmful is often voiced first by the ICU team, which then broaches the issue with the family or surrogate decision maker. Thus, barely a few years after the creation of ICUs, intensivists realized that, in addition to fighting death, their duties included the daunting task of accepting and managing death. This task requires (a) identifying situations in which all hope of recovery is lost and life-prolonging treatments become death-prolonging treatments, which should be withdrawn or withheld; (b) promptly initiating a continuous process of family care based on sensitive and straightforward information and communication; and (c) improving the ability to manage death, via epidemiologic studies of practices, interventional studies of end-of-life strategies, and continuing education aimed at honing the information and communication skills of all ICU professionals. Warding off death and restoring self-sufficiency have been the main goals of intensivists for decades; now, ICU professionals are becoming acutely aware that they must develop a professional approach to dying patients, learn what makes a “good death,” and provide dying patients and their families with support, reassurance, comfort, dignity, and freedom from guilt.
The literature on end of life in ...