Guidance for End-of-Life Care in Critical Care

A post written by Professor Melissa Bloomer - reproduced with kind permission from End-of-Life Essentials.

The traditional goals of treatment in critical care, such as an intensive care unit (ICU), are to reduce morbidity and mortality associated with critical illness, maintain organ function, and restore health. It is probably safe to say that prior to COVID-19, community perceptions about ICU care were that no matter how sick a person was, death was preventable. The endless media coverage and reporting of daily COVID-19 data about cases, ICU admission and deaths has changed that, highlighting that there are limits to what can be done to prevent death. In fact, the latest data suggests ICU mortality rates range from 10-29%[1], with most deaths occurring following a decision to withhold or withdraw life-sustaining treatment[2]. These data really highlight how, even in the ICU, having a workforce who are skilled, educationally and emotionally prepared for their role in the provision of end-of-life care is just as important as other aspects of ICU care.

We know that caring for a dying patient is not just about clinical care. In order to plan appropriate care, first there has to be a recognition that a person may die, and opportunity for consultation amongst the entire treating team. Then, engaging in open dialogue with the next-of-kin and/or extended family in a way that is sensitive to their needs and level of understanding is key. We know that some of the greatest challenges in navigating communication in this situation are knowing who to talk to, working out how much information they want, and what words to use, particularly when there may be cultural differences. There is also perhaps a fine line between using terms that might be considered gentler, and using the correct words to ensure understanding. For most clinicians, it’s not easy.

Informal conversations at the patient’s bedside, such as those between a nurse and the next-of-kin or family are rarely comprehensively documented in the medical record. Yet they can be most important and influential. The nurse-family relationship is not only essential to understanding the patient and family unit, but also to keeping family members informed, demonstrating respect, and supporting families before death and in their bereavement.

Practices in end-of-life care vary widely. Knowing what to do and how to do it is often modelled on others, as well as trial and error. Unit practices also influence the provision of end-of-life care. Whilst the Australian and New Zealand Intensive Care Society (ANZICS) provide a statement on care and decision making at the end of life[3], the statement is written from a dominant medical perspective, with little guidance for nurses about their role in care of the dying, extending to the family. In response, the Australian College of Critical Care Nurses (ACCCN) supported the development of a national position statement to provide nurses with clear practice recommendations to guide the provision of end-of-life care for adults, which reflects the most relevant research evidence for the Australian context[4]. The position statement provides practical guidance about family-centred care, communication and decision-making, patient comfort and family support, the potential for organ donation, care after death and nurse self-care. Importantly, the practice recommendations are written in a way that they can be adopted in accordance with local unit practices, resources, staffing and patient profiles. The practice recommendations are not the panacea to solving the challenges associated with end-of-life care in critical care, but perhaps provide an evidence-based starting point to guide care.

References

1. Society of Critical Care Medicine. Critical Care Statistics 2022 [Available from: https://www.sccm.org/Communications/Critical-Care-Statistics]
2. Lesieur O, Leloup M, Gonzalez F, Mamzer M-F, group Es. Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units. Annals of Intensive Care. 2015;5(1):15. https://doi.org/10.1186/s13613-015-0056-x
3. Australian and New Zealand Intensive Care Society. ANZICS Statement on Care and Decision-Making at the End of Life for the Critically Ill. Carlton South: ANZICS; 2014.
4. Bloomer MJ, Ranse K, Butler A, Brooks L. A national Position Statement on adult end-of-life care in critical care. Australian Critical Care. 2022;35(4):480 7. https://doi.org/10.1016/j.aucc.2021.06.006

Professor Melissa Bloomer
Professor in Critical Care Nursing,
Griffith University and Princess Alexandra Hospital ICU, Brisbane

This blog has been reproduced with kind permission from End-of-Life Essentials.