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Death in the ICU: why integrate palliative care?

  • L. Scott Wilner
  • M. A. DeVita

Abstract

As society increasingly demands better end-of-life care, it is incumbent upon critical care practitioners in particular to learn to manage death and dying with the same expertise they bring to other complex problems encountered in the care of critically ill patients. Patients dying — and surviving — in a critical care unit should be cared for by providers with expertise in palliative care and critical care. It is possible, but not necessary, that a single provider may be able to have both skill sets. The proposition that there is a place for palliative care in the critical care unit is not unchallenged, and is ambitious. Nevertheless, it is not unrealistic and demands further exploration. There is significant data indicating that many intensive care unit (ICU) patients’ needs are unmet by current practice patterns. There is also preliminary data indicating that integrating palliative care practice into the ICU environment is not only feasible, but results in improved outcome (though not survival). Incorporating palliative care into critical care practice will require considerable attitude change and education. The ideal methodology for educating critical care professionals and trainees in end-of-life care continues to evolve as a work in progress. We believe that there is no longer any doubt that competence in these matters — such as conducting a resuscitation, managing a ventilator, or placing vascular access — will be a requisite fundamental skill for intensivists in the future.

Keywords

Intensive Care Unit Palliative Care Critical Care Intensive Care Unit Patient Critical Care Unit 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Campbell ML, Guzman JA (2003) Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest 123: 266–271PubMedCrossRefGoogle Scholar
  2. 2.
    Danis M (1998) Improving end-of-life care in the intensive care unit: what’s to be learned from outcomes research? New Horiz 6: 110–118PubMedGoogle Scholar
  3. 3.
    Truog RD, Burns JP (2002) Excellence in end-of-life care: a goal for intensivists. Intensive Care Med 28: 1197–1199CrossRefGoogle Scholar
  4. 4.
    Curtis RJ, Rubenfeld GD (2001) Introducing the Concept of Managing Death in the ICU. In: Curtis JR, Rubenfeld GD (eds) Managing death in the ICU. Oxford University Press, New York, pp 3–6Google Scholar
  5. 5.
    Prendergast TJ, Puntillo KA (2002) Withdrawal of life support: intensive caring at the end of life. JAMA 288: 2732–2740PubMedCrossRefGoogle Scholar
  6. 6.
    Parks L (1996) Society of Critical Care Medicine initiative to address care at the end of life. Crit Care Med 24: 1106PubMedCrossRefGoogle Scholar
  7. 7.
    Truog RD, Cist AF, Brackett SE et al (2001) Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 29: 2332–2348PubMedCrossRefGoogle Scholar
  8. 8.
    Faber-Langendoen K, Lanken PN (2000) Dying patients in the intensive care unit: forgoing treatment, maintaining care. Ann Intern Med 133: 886–893PubMedGoogle Scholar
  9. 9.
    Faber-Langendoen K (2000) Forgoing treatment, maintaining care. J Palliat Care 16 Suppl: S7–8Google Scholar
  10. 10.
    Rocker GM, Shemie SD, Lacroix J (2000) End-of-life issues in the ICU: a need for acute palliative care? J Palliat Care 16 Suppl: S5–6Google Scholar
  11. 11.
    Miller FG, Fins JJ (1996) A proposal to restructure hospital care for dying patients. N Engl J Med 334: 1740–1742PubMedCrossRefGoogle Scholar
  12. 12.
    Jastremski CA (2001) Caring for those who need critical care: understanding the patient experience. Crit Care Med 29: 449–450PubMedCrossRefGoogle Scholar
  13. 13.
    Nelson JE, Danis M (2001) End-of-life care in the intensive care unit: where are we now? Crit Care Med 29 (2 Suppl): N2–9PubMedCrossRefGoogle Scholar
  14. 14.
    Mosenthal AC, Lee KF, Huffman J (2002) Palliative care in the surgical intensive care unit. J Am Coll Surg 194: 75–83PubMedCrossRefGoogle Scholar
  15. 15.
    The SUPPORT Principal Investigators (1995) A controlled trial to improve care for terminally ill hospitalized adults. JAMA 274: 1591–1598CrossRefGoogle Scholar
  16. 16.
    Freeborne N, Lynn J, Desbiens NA (2000) Insights about dying from the SUPPORT Project. J Amer Geri Soc 48 (5 Suppl):S 199–205Google Scholar
  17. 17.
    Lynn J, Teno JM, Phillips RS, et al (1997) Perceptions by family members of the dying experience of older and seriously ill patients. Ann Intern Med 126: 97–106PubMedGoogle Scholar
  18. 18.
    Nelson JE, Meier DE, Oei EJ, et al (2001) Self-reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med 29 (2): 277–282PubMedCrossRefGoogle Scholar
  19. 19.
    Boland M (1977) Care of the dying patient in intensive care areas. Nurs Mirror 145: 20–21PubMedGoogle Scholar
  20. 20.
    Davidson P, Introna K, Daly J, et al (2003) Cardiorespiratory nurses’ perceptions of palliative care in nonmalignant disease: data for the development of clinical practice. Am J Crit Care 12: 47–53PubMedGoogle Scholar
  21. 21.
    McClement SE, Degner LF (1995) Expert nursing behaviors in care of the dying adult in the intensive care unit. Heart Lung 24: 408–419PubMedCrossRefGoogle Scholar
  22. 22.
    Asch DA (1996) The role of critical care nurses in euthanasia and assisted suicide. N Engl J Med 334: 1374–1379PubMedCrossRefGoogle Scholar
  23. 23.
    Puntillo KA, Benner P, Drought T, et al (2001) End-of-life issues in intensive care units: a national random survey of nurses’ knowledge and beliefs. Am J Crit Care 10: 216–229PubMedGoogle Scholar
  24. 24.
    Karlawish JH, Hall JB (1997) Managing death and dying in the intensive care unit. Am J Respir Crit Care Med 155: 1–2PubMedGoogle Scholar
  25. 25.
    Levy MM (2001) Evaluating our end-of-life practice. Crit Care (London) 5: 182–183CrossRefGoogle Scholar
  26. 26.
    Levy, MM (2001) Making a personal relationship with death. In: Curtis JR, Rubenfeld GD (eds) Managing death in the ICU. Oxford University Press, New York, pp 31–35Google Scholar
  27. 27.
    Holzapfel L, Demingeon G, Piralla B, et al (2002) A four-step protocol for limitation of treatment in terminal care. An observational study in 475 intensive care unit patients. Intensive Care Med 28: 1309–1315PubMedCrossRefGoogle Scholar
  28. 28.
    Faber-Langendoen K (1994) The clinical management of dying patients receiving mechanical ventilation. A survey of physician practice. Chest 106: 880–888PubMedCrossRefGoogle Scholar
  29. 29.
    Kollef MH (1996) Private attending physician status and the withdrawal of life-sustaining interventions in a medical intensive care unit population. Crit Care Med 24: 968–975PubMedCrossRefGoogle Scholar
  30. 30.
    Kollef MH, Ward S (1999) The influence of access to a private attending physician on the withdrawal of life-sustaining therapies in the intensive care unit. Crit Care Med 27: 2125–2132PubMedCrossRefGoogle Scholar
  31. 31.
    Christakis NA, Asch DA (1993) Biases in how physicians choose to withdraw life support. Lancet 342: 642–646PubMedCrossRefGoogle Scholar
  32. 32.
    Christakis NA, Asch DA (1995) Medical specialists prefer to withdraw familiar technologies when discontinuing life support. J Gen Int Med 10: 491–494CrossRefGoogle Scholar
  33. 33.
    Nash I (1984) An ICU death: a Gordian knot in search of Alexander. N Engl J Med 311 (26): 1705PubMedGoogle Scholar
  34. 34.
    Moeller RA (1993) If doctors can’t die with dignity, who can? Med Econ 70(17):30, 33–34, 36Google Scholar
  35. 35.
    Levetown M (1998) Palliative care in the intensive care unit. New Horiz 6: 383–397PubMedGoogle Scholar
  36. 36.
    Cook DJ (2001) Transdisciplinary research to understand the role of bias and heuristics. In: Curtis JR, Rubenfeld GD (eds) Managing death in the ICU. Oxford University Press, New York, pp 59–67Google Scholar
  37. 37.
    Mularski RA, Bascom P, Osborne ML (2001) Educational agendas for interdisciplinary end-oflife curricula. Crit Care Med 29 (2 Suppl): N16 - N23PubMedCrossRefGoogle Scholar
  38. 38.
    Danis M, Federman D, Fins JJ, et al (1999) Incorporating palliative care into critical care education: principles, challenges, and opportunities. Crit Care Med 27: 2005–2013PubMedCrossRefGoogle Scholar
  39. 39.
    Brody H, Campbell ML, Faber-Langendoen K et al (1997) Withdrawing intensive life-sustaining treatment — recommendations for compassionate clinical management. N Engl J Med 336: 652–657PubMedCrossRefGoogle Scholar
  40. 40.
    Fisher M (2002) ICU Cornerstone: a lecture that changed my practice. Crit Care (London) 6: 403–404CrossRefGoogle Scholar
  41. 41.
    Levy MM (2001) End-of-life care in the intensive care unit: can we do better? Crit Care Med 29 Suppl.: N56 - N61Google Scholar
  42. 42.
    Jastremski CA (1998) Caring for the families of those who die in the critical care unit. Crit Care Med 26: 1150–1151PubMedCrossRefGoogle Scholar
  43. 43.
    Coyle N, Truog RD (1994) HealthCare Ethics Forum ‘84: pain management and sedation in the terminally ill. AACN Clin Issues Crit Care Nurs 5: 360–365PubMedGoogle Scholar
  44. 44.
    Phillips RS, Wenger NS, Teno J, et al (1996) Choices of seriously ill patients about cardiopulmonary resuscitation: correlates and outcomes. SUPPORT Investigators. Am J Med 100: 128–137PubMedCrossRefGoogle Scholar
  45. 45.
    Dunn GP, Milch RA, Mosenthal AC, et al (2002) Palliative care by the surgeon: how to do it. J Am Coll Surg 194: 509–537PubMedCrossRefGoogle Scholar
  46. 46.
    Campbell ML, Field BE (1991) Management of the patient with do not resuscitate status: compassion and cost containment. Heart Lung 20: 345–348PubMedGoogle Scholar
  47. 47.
    Campbell ML (1996) Program assessment through outcomes analysis: efficacy of a comprehensive supportive care team for end-of-life care. AACN Clin Issues Crit Care Nurs 7: 159–167Google Scholar
  48. 48.
    Pronovost P, Angus DC (2001) Economics of end-of-life care in the intensive care unit. Crit Care Med 29 (2 Suppl): N46–51PubMedCrossRefGoogle Scholar
  49. 49.
    Marik PE (1995) The cost of dying. Am J Crit Care 4: 56–58PubMedGoogle Scholar
  50. 50.
    Crippen DW (2003) End of life care in the ICU: toward a newer concept of futility. In: Vincent JL (ed) 2003 Yearbook of intensive care and emergency medicine. Springer, HeidelbergGoogle Scholar
  51. Rushton CH, Williams MA. Sabatier KH (2002) The integration of palliative care and critical care: one vision, one voice. Crit Care Nurs Clin North Am 14:133–140Google Scholar
  52. 52.
    Wanzer SH, Federman DD (1989) The physician’s responsibility toward hopelessly ill patients: a second look. N Engl J Med 320: 844–849PubMedCrossRefGoogle Scholar
  53. 53.
    Cassel CK (1996) Hospital care for dying patients (letter). N Engl J Med 335: 1765–1767PubMedCrossRefGoogle Scholar
  54. 54.
    Hill L (1996) Hospital care for dying patients (letter). N Engl J Med 335: 1765–1767CrossRefGoogle Scholar
  55. 55.
    Daly BJ (2000) Organizational change and delivery of multidisciplinary palliative care. Respir Care 45: 1501–1510PubMedGoogle Scholar
  56. 56.
    Curtis JR (1998) The “patient-centered” outcomes of critical care: what are they and how should they be used? New Horiz 6: 26–32PubMedGoogle Scholar
  57. 57.
    Emanuel LL, von Gunten CF, Ferris FD (1999) The Education for Physicians on End-of-life Care (EPEC) curriculum. American Medical Association, ChicagoGoogle Scholar
  58. 58.
    DeVita MA, Arnold RM, Barnard D (2003) Teaching palliative care to critical care medicine trainees. Crit Care Med 31: 1257–1262PubMedCrossRefGoogle Scholar
  59. 59.
    Azoulay E, Chevret S, Leleu G, et al (2000) Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 28: 3044–3049PubMedCrossRefGoogle Scholar
  60. DeVita M, Sirio CA. Paronish R. et al (1999) ICU Patients Are Unlikely to Receive Council Regarding Levels of Support. Chest I I 6:239SGoogle Scholar
  61. 61.
    Lilly CM, De Meo DL, Sonna LA, et al (2000) An intensive communication intervention for the critically ill. Am J Med 109: 469–475PubMedCrossRefGoogle Scholar
  62. 62.
    Anonymous (1976) Optimum care for hopelessly ill patients. A report of the Clinical Care Committee of the Massachusetts General Hospital. N Engl J Med 295: 362–364CrossRefGoogle Scholar
  63. 63.
    Rubenfeld GD, Randall Curtis J (2001) The End-of-Life Care in the ICU Working Group. End-of-life care in the intensive care unit: a research agenda. Crit Care Med 29: 2001–2006PubMedCrossRefGoogle Scholar
  64. 64.
    Levy MM (2001) Paying attention to death. Crit Care Med 29: 2037–2038PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia, Milano 2004

Authors and Affiliations

  • L. Scott Wilner
  • M. A. DeVita

There are no affiliations available

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