Background: These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence.
Principal Findings: Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient’s death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula.
Conclusions: End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.
From Harvard Medical School and Children’s Hospital, Boston, MA (RDT); Detroit Medical Center and Center for Palliative Care Excellence, Wayne State University, Detroit, MI (MLC); University of Washington, Seattle, WA (JRC); Department of Pharmacy, Strong Health, and Department of Surgery, School of Medicine and Dentistry, University of Rochester, Rochester, NY (CEH); University of California, San Francisco, CA (JML); Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA (GDR); Harriet Lane Compassionate Care and Berman Bioethics Institute, Johns Hopkins University and Children’s Center, Baltimore, MD (CHR); and University of Rochester, Rochester, NY (DCK).
The American College of Critical Care Medicine (ACCM), which honors individuals for their achievements and contributions to multidisciplinary critical care medicine, is the consultative body of the Society of Critical Care Medicine (SCCM), which possesses recognized expertise in the practice of critical care. The ACCM has developed administrative guidelines and clinical practice parameters for the critical care practitioner. New guidelines and practice parameters are continually developed, and current ones are systematically reviewed and revised.
Dr. Rubenfeld has held a consultancy with VERICC. The remaining authors have not disclosed any potential conflicts of interest.
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