Discussing End-of-Life Decisions in the ICU-Are We Doing Our Best?* Sigal Sviri, MD Peter Vernon van Heerden, MD, PhD Medical Intensive Care Unit Hadassah Hebrew University Medical Center Jerusalem, Israel
nonresponders. Nonetheless a simple "focusing" action like assessing and thinking about probable functional outcome of the patient may improve discussion of EOL care in the ICU. Additionally, steps such as the formulation of professional guidelines, emphasizing the importance of communicating with families and sharing the decision-making process, evalulthough end-of-life (EOL) care of patients in the ICU ation and improvement of quality of care, and encouragement of EOL research may be taken to assess and influence EOL attiis quite common, we still find this issue complex and tudes in the intensive care environment, in the aim of improvchallenging in many ways, including diverse attitudes ing caretakers' understanding of the process, as well as patient of physicians and nurses, difficulties in communication, and and family care (8). family dilemmas. EOL care encompasses many factors but includes withholding life-sustaining treatment, withdrawing Such techniques may help with regard to the many known life-sustaining treatment, and palliative care (1). It is well recbarriers to effective discussion of EOL matters with patients ognized that there are large variations in the approach and attior their families in the ICU, such as unrealistic family expectatude to these matters between physicians, nurses, and patients tions, inability of the patient to take part in discussions due to and their families (2,3) and that these differences maybe influincompetence, lack of advance directives (ADs) ofthe patient's enced by region (4) and other factors, such as religion and reliwishes, insufficient training of physicians, lack of time and a giosity (5). EOL care in the ICU represents a major source of place for proper EOL discussions, and lack of palliative care stress and is a recognized cause of burnout among healthcare services in the hospital (9). Civen that 20% of Americans practitioners in critical care medicine (6). die after a stay in an ICU (9), any measure to improve EOL discussion would be greatly beneficial. Although it is well known that it takes time and adequate training to acquire the skills needed to work effectively as The fact that patient wishes did not greatly influence the a physician in the ICU, it seems that less attention has been intent to discuss withdrawal of life-sustaining therapy (7) has lavished on training in how to deal with the difficult ethical been alluded in other contexts such as the minimal effect and issues, such as EOL care we as practitioners face every day. In sometimes negative effect of ADs in influencing decision makthis issue of Critical Care Medicine, Turnbull et al (7) report ing by intensive care physicians (10-12). This phenomenon on a scenario-based trial in a large cohort of intensive care may be part of the observation that there are big differences physicians in which they assess factors influencing the intent between the perceived outcome of patients in the ICU between to discuss withdrawal of life support. Interestingly, it appears caregivers and the relatives of patients (2, 3). Perhaps, in this that known patient wishes are less important in influencing context, doctors are doing what is "best for the patient" based the documented intent to discuss withdrawal of life support on their knowledge and experience, even when this is contrary than the action of estimating 3-month functional outcome to stated and documented patient wishes, as politically incorfor the patient. It appears that prognosticating outcome had rect and unpalatable as this may appear. Related to this, it is a "focusing effect" on the physician with regard to the inteninteresting to note that in some jurisdictions, there are formal tion to discuss withdrawal of life support. These findings are processes, outside of the purely legal system, for resolution of indeed interesting and are detracted from by the fact that the conflicts between healthcare providers and patients or their responses are based on hypothetical scenarios, with the main surrogates when EOL expectations do not coincide (13). Howoutcome being the intent to discuss withdrawal of therapy at ever, families are still perceived as being the patients' represena hypothetical family meeting. Additionally, there was a 39% tatives, knowing and conveying their attitudes and preferences response rate to the invitation to participate, which, as the and therefore must be listened to. More so, sometimes famiauthors concede, may have biased the results somewhat in that lies' needs influence EOL practices, such as increasing levels of responders may have been more interested in this topic than sedation to alleviate distress of seeing their loved ones at their last hours and taking into consideration the burden of looking after patients with limited functionality and increased discom'See also p. 1455. fort and even suffering (1). Key Words: communication; decision making; end ot lite; intensive care; Communication is the key to successful EOL challenges, relatives often requiring multiple meetings for all the information to be The authors have disclosed that they do not have any potential contlicts transmitted and assimilated and for appropriate decisions to ot interest. be made (1,14). EOL discussions are usually not easy and take Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins great care and sensitivity. Without doubt, such discussions are easier when the treating team senior member or spokesperson DOI: 10.1097/CCM.0000000000000284
A
1560
www.ccmjournal.org
June 2014 • Volume 42 • Number 6
Editorials
speaks with "one voice" on behalf of the treating team (i.e., there is consensus in the treating team before the patient or family is approached). Physician training in the art of effective and empathie communication is encouraged by attending specific courses and by observing the actions and techniques of mentors. In some training bodies, such as the GoUege of Intensive Gare Medicine of Australia and New Zealand, this training is encouraged by the inclusion of communications scenarios in the final specialist examinations in intensive care medicine and by mandating courses on communication of difficult and bad news. Discussing EOL matters is difficult for us in the IGU, where we deal with the subject on a day-to-day basis. How much more so it must be for colleagues who work on the wards. It is therefore incumbent on intensive care physicians to improve their skills in this field and to remember that just because we may be withdrawing or withholding "active" care does not mean we are not doing what is best for our patients and that we never stop caring for them.
REFERENCES 1. Truog RD, Cist AF, Brackett SE, et al: Reoommendations for end-ofiife oare in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 2001 ; 29:2332-2348 2. Sprung CL, Carmel S, Sjokvist P, et al; ETHICATT Study Group: Attitudes of European physicians, nurses, patients, and families regarding end-of-life decisions: The ETHICATT study, intensive Care Med 2007; 33:104-110 3. Levy CR, Ely EW, Payne K, et al: Quality of dying and death in two medioal ICUs: Perceptions of family and olinioians. Chest 2005; 127:1775-1783
4. Giannini A, Pessina A, Tacchi EM: End-of-life decisions in intensive oare units: Attitudes of physicians in an Italian urban setting. Intensive Care Med 2003; 29:1902-1910 5. Bülow HH, Sprung CL, Baras M, et al: Are religion and religiosity important to end-of-life deoisions and patient autonomy in the ICU? The Ethicatt study, intensive Care Med 2012; 38:1126-1133 6. Piers RD, Azoulay E, Rioou B, et ai; APPROPRICUS Study Group of the Ethics Section of the ESICM: Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physioians. JAMA 2011 ; 306:2694-2703 7. Turnbuli AE, Krali JR, Ruhl AP, et al: A Scenario-Based, Randomized Trial of Patient Values and Functional Prognosis on Intensivist Intent to Discuss Withdrawing Life Support. Crit Care Med 2014; 42:1455-1462 8. Cook D, Rooker G, Giaoomini M, et al: understanding and changing attitudes toward withdrawal and withholding of life support in the intensive oare unit. Crit Care Med 2006; 34:S317-S323 9. Nelson JE, Angus DC, Weissfeld LA, et ai; Critical Care Peer Workgroup of the Promoting Exceilence in End-of-Life Care Project: End-of-life oare for the oritioally ill: A nationai intensive oare unit survey. Crit Care Med 2006; 34:2547-2553 10. Gutierrez KM: Advance directives in an intensive oare unit: Experiences and recommendations of criticai care nurses and physicians. Crit Care Nurs Q 201 2; 35:396-409 11. Hartog CS, Pesohel I, Schwarzkopf D, et al: Are written advanoe directives helpful to guide end-of-life therapy in the intensive oare unit? A retrospeotive matohed-oohort study. J Crit Care 2014; 29:128-133 12. Piers RD, Benoit DD, Sohrauwen WJ, et al: Do-not-resuscitate deoisions in a large tertiary hospital: Differenoes between wards and results of a hospital-wide intervention. Acta din Beig 2011 ; 66:116-122 13. Chidwiok P, Sibbald R: Physician perspectives on legal processes for resolving end-of-life disputes. Heaithc Q 2011 ; 14:69-74 14. Curtis JR, Vincent JL: Ethics and end-of-life care for adults in the intensive oare unit. Lancet 2010; 376:1347-1353
Hypercapnia and Neuroprotection: Goldilocks Returns* G. Bryan Young, MD, FRCPC Department of Clinical Neurological Sciences Western University London, CN, Canada
using the Gerebral Performance Gategory at 12 months. On the other hand, Pao^ values showed no correlation with outcome. The perhaps unexpected findings are in keeping with benefits of "permissive hypercapnia" on the brain as found in animal models and some human studies (2-4). Zhou et al n this issue of Critical Care Medicine, Vaahersalo et al ( 1 ) (4) produced cerebral ischemia in rats by bilateral carotid occlusion and hypotension for 15 minutes, and then allowed conducted a prospective, observational study on patients reperfusion, while allowing varied concentrations of Paco^. resuscitated from cardiac arrest and measured Pao^ and Moderate hypercapnia (Paco^, 60-100 mm Hg) groups showed PacOj, respectively. Their meta-analysis revealed that the mean values of Paco^ greater than 45 mm Hg averaged over the first better neurologic scores, less histological brain damage, and 24 hours from admission correlated with good outcomes. less apoptosis than did normocapnic or markedly hypercapnic (Paco^, 100-120 mm Hg) groups. Interestingly, the latter group had marked cerebral edema. This strongly suggests a "Goldilocks effect" with an optimal concentration of Paco^. 'See also p. 1463. Lowering Paco^ causes vasoconstriction and reduces blood Key Words: cardiac arrest; hyperoapnia; hypothermia; neuroprotection flow, whereas increasing Paco^ leads to increased bloodflow.It Dr. Young consulted for and reoeived support for travel from GE Healthcare. suggests that mild increase in GBF might be beneficial. HowCopyright © 2014 by the Society of Critical Care Medioine and Lippincott ever, benefit might not be so simple and there are some potenWilliams & Wilkins tial downsides. DOI:10.1097/CCM.0000000000000276
I
Critical Care Medicine
www.ccmjournal.org
1561
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
nonresponders. Nonetheless a simple "focusing" action like assessing and thinking about probable functional outcome of the patient may improve discussion of EOL care in the ICU. Additionally, steps such as the formulation of professional guidelines, emphasizing the importance of communicating with families and sharing the decision-making process, evalulthough end-of-life (EOL) care of patients in the ICU ation and improvement of quality of care, and encouragement of EOL research may be taken to assess and influence EOL attiis quite common, we still find this issue complex and tudes in the intensive care environment, in the aim of improvchallenging in many ways, including diverse attitudes ing caretakers' understanding of the process, as well as patient of physicians and nurses, difficulties in communication, and and family care (8). family dilemmas. EOL care encompasses many factors but includes withholding life-sustaining treatment, withdrawing Such techniques may help with regard to the many known life-sustaining treatment, and palliative care (1). It is well recbarriers to effective discussion of EOL matters with patients ognized that there are large variations in the approach and attior their families in the ICU, such as unrealistic family expectatude to these matters between physicians, nurses, and patients tions, inability of the patient to take part in discussions due to and their families (2,3) and that these differences maybe influincompetence, lack of advance directives (ADs) ofthe patient's enced by region (4) and other factors, such as religion and reliwishes, insufficient training of physicians, lack of time and a giosity (5). EOL care in the ICU represents a major source of place for proper EOL discussions, and lack of palliative care stress and is a recognized cause of burnout among healthcare services in the hospital (9). Civen that 20% of Americans practitioners in critical care medicine (6). die after a stay in an ICU (9), any measure to improve EOL discussion would be greatly beneficial. Although it is well known that it takes time and adequate training to acquire the skills needed to work effectively as The fact that patient wishes did not greatly influence the a physician in the ICU, it seems that less attention has been intent to discuss withdrawal of life-sustaining therapy (7) has lavished on training in how to deal with the difficult ethical been alluded in other contexts such as the minimal effect and issues, such as EOL care we as practitioners face every day. In sometimes negative effect of ADs in influencing decision makthis issue of Critical Care Medicine, Turnbull et al (7) report ing by intensive care physicians (10-12). This phenomenon on a scenario-based trial in a large cohort of intensive care may be part of the observation that there are big differences physicians in which they assess factors influencing the intent between the perceived outcome of patients in the ICU between to discuss withdrawal of life support. Interestingly, it appears caregivers and the relatives of patients (2, 3). Perhaps, in this that known patient wishes are less important in influencing context, doctors are doing what is "best for the patient" based the documented intent to discuss withdrawal of life support on their knowledge and experience, even when this is contrary than the action of estimating 3-month functional outcome to stated and documented patient wishes, as politically incorfor the patient. It appears that prognosticating outcome had rect and unpalatable as this may appear. Related to this, it is a "focusing effect" on the physician with regard to the inteninteresting to note that in some jurisdictions, there are formal tion to discuss withdrawal of life support. These findings are processes, outside of the purely legal system, for resolution of indeed interesting and are detracted from by the fact that the conflicts between healthcare providers and patients or their responses are based on hypothetical scenarios, with the main surrogates when EOL expectations do not coincide (13). Howoutcome being the intent to discuss withdrawal of therapy at ever, families are still perceived as being the patients' represena hypothetical family meeting. Additionally, there was a 39% tatives, knowing and conveying their attitudes and preferences response rate to the invitation to participate, which, as the and therefore must be listened to. More so, sometimes famiauthors concede, may have biased the results somewhat in that lies' needs influence EOL practices, such as increasing levels of responders may have been more interested in this topic than sedation to alleviate distress of seeing their loved ones at their last hours and taking into consideration the burden of looking after patients with limited functionality and increased discom'See also p. 1455. fort and even suffering (1). Key Words: communication; decision making; end ot lite; intensive care; Communication is the key to successful EOL challenges, relatives often requiring multiple meetings for all the information to be The authors have disclosed that they do not have any potential contlicts transmitted and assimilated and for appropriate decisions to ot interest. be made (1,14). EOL discussions are usually not easy and take Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins great care and sensitivity. Without doubt, such discussions are easier when the treating team senior member or spokesperson DOI: 10.1097/CCM.0000000000000284
A
1560
www.ccmjournal.org
June 2014 • Volume 42 • Number 6
Editorials
speaks with "one voice" on behalf of the treating team (i.e., there is consensus in the treating team before the patient or family is approached). Physician training in the art of effective and empathie communication is encouraged by attending specific courses and by observing the actions and techniques of mentors. In some training bodies, such as the GoUege of Intensive Gare Medicine of Australia and New Zealand, this training is encouraged by the inclusion of communications scenarios in the final specialist examinations in intensive care medicine and by mandating courses on communication of difficult and bad news. Discussing EOL matters is difficult for us in the IGU, where we deal with the subject on a day-to-day basis. How much more so it must be for colleagues who work on the wards. It is therefore incumbent on intensive care physicians to improve their skills in this field and to remember that just because we may be withdrawing or withholding "active" care does not mean we are not doing what is best for our patients and that we never stop caring for them.
REFERENCES 1. Truog RD, Cist AF, Brackett SE, et al: Reoommendations for end-ofiife oare in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 2001 ; 29:2332-2348 2. Sprung CL, Carmel S, Sjokvist P, et al; ETHICATT Study Group: Attitudes of European physicians, nurses, patients, and families regarding end-of-life decisions: The ETHICATT study, intensive Care Med 2007; 33:104-110 3. Levy CR, Ely EW, Payne K, et al: Quality of dying and death in two medioal ICUs: Perceptions of family and olinioians. Chest 2005; 127:1775-1783
4. Giannini A, Pessina A, Tacchi EM: End-of-life decisions in intensive oare units: Attitudes of physicians in an Italian urban setting. Intensive Care Med 2003; 29:1902-1910 5. Bülow HH, Sprung CL, Baras M, et al: Are religion and religiosity important to end-of-life deoisions and patient autonomy in the ICU? The Ethicatt study, intensive Care Med 2012; 38:1126-1133 6. Piers RD, Azoulay E, Rioou B, et ai; APPROPRICUS Study Group of the Ethics Section of the ESICM: Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physioians. JAMA 2011 ; 306:2694-2703 7. Turnbuli AE, Krali JR, Ruhl AP, et al: A Scenario-Based, Randomized Trial of Patient Values and Functional Prognosis on Intensivist Intent to Discuss Withdrawing Life Support. Crit Care Med 2014; 42:1455-1462 8. Cook D, Rooker G, Giaoomini M, et al: understanding and changing attitudes toward withdrawal and withholding of life support in the intensive oare unit. Crit Care Med 2006; 34:S317-S323 9. Nelson JE, Angus DC, Weissfeld LA, et ai; Critical Care Peer Workgroup of the Promoting Exceilence in End-of-Life Care Project: End-of-life oare for the oritioally ill: A nationai intensive oare unit survey. Crit Care Med 2006; 34:2547-2553 10. Gutierrez KM: Advance directives in an intensive oare unit: Experiences and recommendations of criticai care nurses and physicians. Crit Care Nurs Q 201 2; 35:396-409 11. Hartog CS, Pesohel I, Schwarzkopf D, et al: Are written advanoe directives helpful to guide end-of-life therapy in the intensive oare unit? A retrospeotive matohed-oohort study. J Crit Care 2014; 29:128-133 12. Piers RD, Benoit DD, Sohrauwen WJ, et al: Do-not-resuscitate deoisions in a large tertiary hospital: Differenoes between wards and results of a hospital-wide intervention. Acta din Beig 2011 ; 66:116-122 13. Chidwiok P, Sibbald R: Physician perspectives on legal processes for resolving end-of-life disputes. Heaithc Q 2011 ; 14:69-74 14. Curtis JR, Vincent JL: Ethics and end-of-life care for adults in the intensive oare unit. Lancet 2010; 376:1347-1353
Hypercapnia and Neuroprotection: Goldilocks Returns* G. Bryan Young, MD, FRCPC Department of Clinical Neurological Sciences Western University London, CN, Canada
using the Gerebral Performance Gategory at 12 months. On the other hand, Pao^ values showed no correlation with outcome. The perhaps unexpected findings are in keeping with benefits of "permissive hypercapnia" on the brain as found in animal models and some human studies (2-4). Zhou et al n this issue of Critical Care Medicine, Vaahersalo et al ( 1 ) (4) produced cerebral ischemia in rats by bilateral carotid occlusion and hypotension for 15 minutes, and then allowed conducted a prospective, observational study on patients reperfusion, while allowing varied concentrations of Paco^. resuscitated from cardiac arrest and measured Pao^ and Moderate hypercapnia (Paco^, 60-100 mm Hg) groups showed PacOj, respectively. Their meta-analysis revealed that the mean values of Paco^ greater than 45 mm Hg averaged over the first better neurologic scores, less histological brain damage, and 24 hours from admission correlated with good outcomes. less apoptosis than did normocapnic or markedly hypercapnic (Paco^, 100-120 mm Hg) groups. Interestingly, the latter group had marked cerebral edema. This strongly suggests a "Goldilocks effect" with an optimal concentration of Paco^. 'See also p. 1463. Lowering Paco^ causes vasoconstriction and reduces blood Key Words: cardiac arrest; hyperoapnia; hypothermia; neuroprotection flow, whereas increasing Paco^ leads to increased bloodflow.It Dr. Young consulted for and reoeived support for travel from GE Healthcare. suggests that mild increase in GBF might be beneficial. HowCopyright © 2014 by the Society of Critical Care Medioine and Lippincott ever, benefit might not be so simple and there are some potenWilliams & Wilkins tial downsides. DOI:10.1097/CCM.0000000000000276
I
Critical Care Medicine
www.ccmjournal.org
1561
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
