CHAPTER 18: Providing Palliative Care and Withholding or Withdrawing Life-Sustaining Therapy

KEY POINTS

• Approximately 20% of deaths in the United States are associated with or occur in an intensive care unit and a substantial majority of these deaths will have some aspect of intensive care treatment either withheld or withdrawn. High-quality care for patients dying in the ICU should incorporate the principles and practice of palliative care and therefore intensive care unit clinicians should familiarize themselves with basic aspects of palliative care.

• High-quality communication with critically ill patients and their family is an essential skill for ICU clinicians and one component of palliative care. Communication about end-of-life issues requires navigating cognitive, emotional, and ethical elements of decision making.

• The use of structured, patient- and family-centered approaches to end-of-life communication improves outcomes among family of deceased ICU patients.

• The provision of high-quality palliative care requires a multidisciplinary approach to effectively address physical, psychosocial, and spiritual suffering.

• An ideal model for palliative care in the ICU should include integrating principles of palliative care into routine ICU practice as well as the use of palliative care, ethics, and spiritual support teams for some patients and family members.

• Withdrawing or withholding life-sustaining therapy is widely accepted and common in the United States. This practice should adhere to the standards for quality medical care including appropriate documentation, attention to detail, an explicit plan for addressing patient, family, and clinician needs, and interdisciplinary implementation. An institutional protocol may help achieve these standards.

THE ROLE OF PALLIATIVE CARE IN THE ICU

DEFINING AND UNDERSTANDING PALLIATIVE CARE IN THE ICU

Palliative care is a unique approach and a distinct model of clinical care when compared to conventional care. It focuses on patients with serious, life-threatening illness and is characterized by three main principles.¹The first principle is that the overarching goal of palliative care is to improve the quality of life through the relief of suffering in each of its major domains: physical, emotional, psychosocial, and spiritual. Thus, follows the second principle that palliative care is provided by an interdisciplinary team that generally includes the professions of medicine, nursing, social work/counseling, and chaplaincy. The third principle is that the patient and family are the focus of care rather than the patient individually. An important feature of palliative care for ICU clinicians to understand is that it can be offered simultaneously with aggressive efforts to extend life and does not impose an “either-or choice” between conventional critical care and palliative care.

Given the substantial risk of death for many critically ill and injured patients, ICU clinicians can enhance important aspects of patient and family outcomes by considering how to integrate these principles into their practices. Although not focused primarily on the relief of suffering, critical care has increasingly begun to value the importance of symptom management,^2-4 emotional and psychological outcomes,⁵ and psychosocial support.^6-8 More generally, investigation into health-related quality of life following ...