64: End-of-Life Issues in Emergency Critical Care

INTRODUCTION

The majority of patients who are admitted to medical and surgical intensive care units (ICUs) often begin their hospital course in the emergency department (ED). Thus, ED clinicians set the stage for the future management trajectory, usually initiating aggressive life-saving measures, with a curative and resuscitative approach to care.^1,2 Due to advances in technology, deaths in most critically ill patients now often result from limitation of life-supporting measures as opposed to a natural decline from disease or age.³ Since the majority of critically ill patients spend the last few days of their life in a hospital, this has resulted in an expansion of the mission of critical care to include provision of the best care available for dying patients and their families.⁴ In 2003, an International Consensus Conference was convened to discuss some of these end-of-life challenges and to address the issues related to optimal care for dying critical care patients.⁵ In order to achieve the best quality of life desired by the patient rather than just an emphasis on the quantity of life regardless of disease or symptom burden, it has become clear that we need to focus on patient values, beliefs, and comfort from the onset of care, regardless of their diagnosis.^2,4,5

Essential to the goal of providing good end-of-life care is understanding a few key concepts: (1) death is not a professional failure, (2) a pain-free death must be assured, (3) effective communication with family and surrogates is needed for shared decision-making, (4) goals-of-care discussions help guide the “shift” from a curative to a comfort approach, and, most importantly, (5) a multidisciplinary team to support patient and family needs throughout the dying process is absolutely essential. This multidisciplinary team ideally would include nurses, physicians in training, social workers, family support personnel, chaplains, and, when appropriate and available, subspecialist palliative care consult teams.⁶ We further discuss the following domains frequently encountered in end-of-life care provision: (1) advance directives; (2) goals-of-care discussions and communication; (3) death-related issues that include delivery of bad news, death notification, and family-witnessed resuscitation (FWR); (4) withdrawal of life support; and (5) palliative care with optimal symptom management at end of life.

ADVANCE DIRECTIVES

Management of a patient at end-of-life is expected to be based on an understanding of what the patient wants and values, shared decision-making, and a respect for patient autonomy. Currently, decision-making in critical care patients varies widely and may not always allow for shared decision-making and may not always defer to patient autonomy.^5,7,8 For example, one major study reported that physicians did not consistently document a do not resuscitate (DNR) order for patients who did not wish to have cardiopulmonary resuscitation (CPR),⁷ whereas another showed that even when DNR orders were present, these were followed only 58% of the time.⁸ Discussions about ...