The majority of patients who are admitted to medical critical care units and many of those in surgical intensive care units 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 critical patients often result from limitation of life-supporting measures as opposed to a natural decline from disease or age.3 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 the 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 rather than just an emphasis on the “quantity” along with cure, it is essential to focus on patient comfort from the onset of care.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 aid in the “shift” from a curative to a comfort approach, and, most important, (5) a multidisciplinary team approach is absolutely essential and should include nurses, house staff, social workers, family support teams, 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.
Currently, decision making in critical care patients varies widely and may not always defer to patient autonomy.5,7,8 A 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 DNR orders were followed only 58% of the time.8 Patient-value-based management and respect for patient autonomy involve a shared decision-making model that may be essential to increasing patient and family satisfaction with critical health care.
Determining Decision-Making Capacity
Determining decision-making capacity is an essential step toward assessing patient needs and values and is decision specific.9 This means that the patient may have the capacity to make one particular decision but not have the same capacity for another. Physicians are responsible for judging capacity, whereas competency is assessed by a judge. A list of questions to help assess capacity include: ...