In our view, this decision is best aided by a clear, brief explanation of the patient's condition and why the physician believes the patient is dying. When the patient or significant other has had the opportunity to challenge or clarify that explanation, the physician needs to make a clear recommendation that continued treatment for cure is most unlikely to be successful, so therapeutic goals should be shifted to treatment for comfort for this dying patient. In our experience, about 90% of such patients or their families understand and agree with the recommendation, most expressing considerable relief that they do not have to make a decision, but rather follow the recommendation of the physician. It is important to provide time and support for the other 10% while they process their reasons for disagreement with the physician's recommendation, but this remains a front-burner issue to be discussed again within 24 hours in most cases.
At this point, patients or their significant others who agree with the recommendation to shift goals from cure to comfort benefit from understanding that comfort care in the ICU constitutes a systematic removal of the causes of patient discomfort, together with the incorporation of comforting interventions of the patient's choice (Table 1-2). For example, treatment for cure often consists of positive-pressure ventilation associated with posturing, chest pummeling and tracheal suctioning, the infusion of vasoactive drugs to enhance circulation, dialysis for renal failure, aggressive intravenous or alimentary nutrition, antibiotics for multiple infections, surgery where indicated, and daily interruption of sedative infusions to allow ongoing confirmation of CNS status. Each of these components of treatment for cure includes uncomfortable interventions that need to be explicitly described so that patients or their significant others do not maintain the misconception that continued ICU care is a harmless, comfortable course of action. By contrast, treatment for comfort consists of intravenous medication effective at relieving pain, dyspnea, and anxiety. It also consists of withholding interventions that cause the patient pain or irritation, and of replacing both interventions and electronic monitoring of vital signs with free access of the family and friends to allow the intensive care cubicle to become a safe place for grieving and dying with psychospiritual support systems maximized. Once an orderly transition from treatment for cure to treatment for comfort has been effected in the ICU, timely transfer out of the unit to an environment that permits death and grieving with privacy and dignity is often appropriate. Whenever possible, continuity of care for the dying patient outside the ICU should be effected by the ICU physician-house staff team to minimize fragmentation of comfort measures and to keep the patient from feeling abandoned.