Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH,
Kaufman DC; American Academy of Critical Care Medicine. Crit Care Med. 2008 Mar;36(3):953-63.
Erratum in:
Crit Care Med. 2008 May;36(5):1699.
Harvard Medical School and Children’s Hospital, Boston, MA, USA.
robert_truog@hms.harvard.edu
BACKGROUND: These recommendations have been developed to improve the care of
intensive care unit (ICU) patients during the dying process. The recommendations
build on those published in 2003 and highlight recent developments in the field
from a U.S. perspective. They do not use an evidence grading system because most
of the recommendations are based on ethical and legal principles that are not
derived from empirically based evidence. PRINCIPAL FINDINGS: Family-centered
care, which emphasizes the importance of the social structure within which
patients are embedded, has emerged as a comprehensive ideal for managing
end-of-life care in the ICU. ICU clinicians should be competent in all aspects of
this care, including the practical and ethical aspects of withdrawing different
modalities of life-sustaining treatment and the use of sedatives, analgesics, and
nonpharmacologic approaches to easing the suffering of the dying process. Several
key ethical concepts play a foundational role in guiding end-of-life care,
including the distinctions between withholding and withdrawing treatments,
between actions of killing and allowing to die, and between consequences that are
intended vs. those that are merely foreseen (the doctrine of double effect).
Improved communication with the family has been shown to improve patient care and
family outcomes. Other knowledge unique to end-of-life care includes principles
for notifying families of a patient’s death and compassionate approaches to
discussing options for organ donation. End-of-life care continues even after the
death of the patient, and ICUs should consider developing comprehensive
bereavement programs to support both families and the needs of the clinical
staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU
has been developed to guide research, quality improvement efforts, and
educational curricula. CONCLUSIONS: End-of-life care is emerging as a
comprehensive area of expertise in the ICU and demands the same high level of
knowledge and competence as all other areas of ICU practice.