Page 35 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

4 PART 1: An Overview of the Approach to and Organization of Critical Care

TABLE 1-1 The Intensivist’s Roles in Deciding to Forego Life-Sustaining TABLE 1-2 Reconsidering the Goals of Therapy
Treatment Cure Comfort
Guiding the Decision Managing the Grief
Ventilation Treat pain
Explanation Patient’s advocate Perfusion Relieve dyspnea
Recommendation Empathic listening Dialysis Allay anxiety
Patient’s response Assemble support Nutrition Minimize interventions
Implementation Acknowledge the loss Treat infection Family access
Surgery Support
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or withdraw ICU care, as distinguished from deaths after CPR or with Differential diagnosis Grieving
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full ICU care but no CPR. One interesting feature of this study was the
heterogeneity among different units, with some units reporting 90% of
deaths associated with withholding and withdrawing ICU care, and oth-
ers reporting less than 10% associated with this decision. Considerable cause the patient pain or irritation, and of replacing both interventions
discussion in the recent literature focuses on the definition of medical and electronic monitoring of vital signs with free access of the family
futility, and many intensive care physicians are perplexed regarding how and friends to allow the intensive care cubicle to become a safe place for
to utilize the vagaries of survivorship data to be confident that continu- grieving and dying with psychospiritual support systems maximized.
ing therapy would be futile. 16,17 Once an orderly transition from treatment for cure to treatment for
Yet many of these same physicians have a clear answer to another comfort has been effected in the ICU, timely transfer out of the unit to
formulation of the question, “Is this patient dying?” An increasing an environment that permits death and grieving with privacy and dig-
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number of critical care physicians are answering yes’ to this question nity is often appropriate. Whenever possible, continuity of care for the
based on their evaluation of the patient’s chronic health history, the dying patient outside the ICU should be effected by the ICU physician-
trajectory of the acute illness, and the number of organ systems cur- house staff team to minimize fragmentation of comfort measures and to
rently failing. When the physician concludes that the patient is dying, keep the patient from feeling abandoned.
often happens in the ICU, to the significant other of the dying patient ■ MANAGE GRIEF
this information needs to be communicated to the patient, or as so
who is unable to communicate and has not left advance directives. The second process that is ongoing during this decision making allows
This communication involves two complex processes: (1) helping the the dying patient or the family and friends to begin to express their
patient or the significant others with the decision to withhold or with- grief (see Table 1-1). The very best care of the patient is care for the
draw life-sustaining therapy and (2) helping them process the grief this patient, and the critical care physician’s demeanor during the decision-
decision entails (Table 1-1). making process goes a long way toward demonstrating that he or she
■ CHANGE THE GOAL OF THERAPY FROM CURE TO COMFORT is acting as the patient’s advocate. The urgent pursuit of an agenda that
care should be withdrawn does not help the patient or family to trust
In our view, this decision is best aided by a clear, brief explanation of the in the physician’s desire to help the patient. Instead, pastoral skills such
patient’s condition and why the physician believes the patient is dying. as empathic listening, assembling the family and other support systems,
When the patient or significant other has had the opportunity to chal- and acknowledging and sharing in the pain while introducing the
lenge or clarify that explanation, the physician needs to make a clear rec- vocabulary of grief processing are constructive ways to help the patient
ommendation that continued treatment for cure is most unlikely to be and family reconsider the goals of therapy. This is not an easy task when
successful, so therapeutic goals should be shifted to treatment for com- the physician knows the patient and family well, but it is even more
fort for this dying patient. In our experience, about 90% of such patients difficult in the modern intensive care environment, when the physician
or their families understand and agree with the recommendation, most may have met the patient for the first time within hours to days preced-
expressing considerable relief that they do not have to make a decision, ing the reconsideration of therapeutic goals. Yet the critical care physi-
but rather follow the recommendation of the physician. It is important cian needs to establish his or her position as a credible advocate for the
to provide time and support for the other 10% while they process their patient by being a source of helpful information, by providing direction
reasons for disagreement with the physician’s recommendation, but this and listening empathically. Because the critical care physician is often
remains a front-burner issue to be discussed again within 24 hours in a stranger, all efforts should be made at the time of reconsidering the
most cases. goals of therapy to assemble support helpful to the patient, including
At this point, patients or their significant others who agree with family friends, the primary physician, the bedside nurse, house staff
the recommendation to shift goals from cure to comfort benefit from and students caring for the patient, appropriate clergy, ethics special-
understanding that comfort care in the ICU constitutes a systematic ists, and social services. Increasingly staff from palliative care services
removal of the causes of patient discomfort, together with the incorpora- become involved in patients dying in the ICU and are particularly
tion of comforting interventions of the patient’s choice (Table 1-2). For important in transitioning end-of-life care to other hospital, hospice,
example, treatment for cure often consists of positive-pressure ventila- or home locations.
infusion of vasoactive drugs to enhance circulation, dialysis for renal ■ COMBINE EXCELLENCE AND COMPASSION
tion associated with chest physiotherapy and tracheal suctioning, the
failure, intravenous or alimentary nutrition, antibiotics for multiple Since up to 90% of patients who die in modern ICUs do so with the
infections, surgery where indicated, and daily interruption of sedative decision to withhold and withdraw life-sustaining therapy, exemplary
infusions to allow ongoing confirmation of CNS status. Each of these critical care should include a commitment to make this transition to
components of treatment for cure includes uncomfortable interventions treatment for comfort a humane and compassionate process, con-
that need to be explicitly described so that patients or their significant ducted with the same expertise and excellence sought during treat-
others do not maintain the misconception that continued ICU care is ment for cure. In our view, the physician’s conclusion that the patient
a harmless, comfortable course of action. By contrast, treatment for is dying is the starting point. Thereafter, the physician’s recommenda-
comfort consists of intravenous medication effective at relieving pain, tion to shift treatment goals from cure to comfort is essential so that
dyspnea, and anxiety. It also consists of withholding interventions that the patient and the family have no illusions that full ICU care will

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