An overview of end-of-life issues in the intensive care unit

Where would Canadians prefer to die? Variation by situational severity, support for family obligations, and age in a national study

Background

Death at home has been identified as a key quality indicator for Canadian health care systems and is often assumed to reflect the wishes of the entire Canadian public. Although research in other countries has begun to question this assumption, there is a dearth of rigorous evidence of a national scope in Canada. This study addresses this gap and extends it by exploring three factors that moderate preferences for setting of death: situational severity (entailing both symptoms and supports), perceptions of family obligation, and respondent age.

Methods

Two thousand five hundred adult respondents from the general population were recruited using online panels between August 2019 and January 2020. The online survey included three vignettes, representing distinct dying scenarios which increased in severity based on symptom management alongside availability of formal and informal support. Following each vignette respondents rated their preference for each setting of death (home, acute/intensive care, palliative care unit, nursing home) for that scenario. They also provided sociodemographic information and completed a measure of beliefs about family obligations for end-of-life care.

Results

Home was the clearly preferred setting only for respondents in the mild severity scenario. As the dying scenario worsened, preferences fell for home death and increased for the other options, such that in the severe scenario, most respondents preferred a palliative care or hospice setting. This pattern was particularly distinct among respondents who also were less supportive of family obligation norms, and for adults 65 years of age and older.

Conclusions

Home is not universally the preferred setting for dying. The public, especially older persons and those expressing lower expectations of families in general, express greater preference for palliative care settings in situations where they might have less family or formal supports accompanied by more severe and uncontrolled symptoms. Findings suggest a) the need for public policy and health system quality indicators to reflect the nuances of public preferences, b) the need for adequate investment in hospices and palliative care settings, and c) continuing efforts to ensure that home-based formal services are available to help people manage symptoms and meet their preferences for setting of death.

A Survey of Clinicians Regarding Goals of Care for Patients with Severe Comorbid Illnesses Hospitalized for an Acute Deterioration

Background

Patients with terminal illnesses hospitalized with acute deteriorations often suffer from unnecessary/inappropriate therapies at the end of their lives. Appropriate advance care planning (ACP) practices aligned to patients’ goals of care may mitigate this.

Materials and methods

To explore the rationale for clinical decision-making in hospitalized patients with terminal illnesses and formulate a practice pathway to streamline care. Between May and December 2018, a questionnaire survey with three case vignettes derived from intensive care unit (ICU) patients was emailed to ICU, respiratory and renal doctors, and nurses in two Sydney hospitals. Respondents chose various management options ranging from all active therapies to palliation. The primary outcome was the proportion of responses for each management option. With these and a thematic analysis of responses to identify barriers to ACP practice, a practice pathway was formulated.

Results

Of the 310 invited clinicians, 178 responded (57.4%). About 89.2% of respondents reported caring for dying patients frequently. Sixty percent saw patients suffering from prolonged therapies. Most respondents deemed patients in the case vignettes to be terminally ill, warranting ACP discussions. However, many still wanted to treat the acute deterioration with active ICU-level interventions. Most respondents reported being comfortable in having ACP discussions.

Conclusion

The survey showed discordance between the stated opinions and the choice of management options for terminally ill patients with acute deteriorations; possibly due to the lack of a considered approach in choosing management options that align with medical consensus and the patient's/family's wishes, a practice pathway is suggested to improve management.

How to cite this article

Sarangi RK, Rajamani A, Lakshmanan R, Srinivasan S, Arvind H. A Survey of Clinicians Regarding Goals of Care for Patients with Severe Comorbid Illnesses Hospitalized for an Acute Deterioration. Indian J Crit Care Med 2022;26(4):457–463.

Ethical considerations at the end-of-life care

The goal of end-of-life care for dying patients is to prevent or relieve suffering as much as possible while respecting the patients’ desires. However, physicians face many ethical challenges in end-of-life care. Since the decisions to be made may concern patients’ family members and society as well as the patients, it is important to protect the rights, dignity, and vigor of all parties involved in the clinical ethical decision-making process. Understanding the principles underlying biomedical ethics is important for physicians to solve the problems they face in end-of-life care. The main situations that create ethical difficulties for healthcare professionals are the decisions regarding resuscitation, mechanical ventilation, artificial nutrition and hydration, terminal sedation, withholding and withdrawing treatments, euthanasia, and physician-assisted suicide. Five ethical principles guide healthcare professionals in the management of these situations.

Challenges and facilitators in providing effective end of life care in intensive care units

Caring for patients who are at the end of their lives is an essential aspect of practice in intensive care units (ICUs). While intensive care is one of the fastest-growing healthcare specialties as a result of technological and scientific advances, a significant proportion of patients admitted to an ICU in the UK will not survive their ICU stay. Therefore, it is important to examine ways to enhance practice in this area and the factors that might affect the care provided to patients and their families.

AIM

To identify the challenges and facilitators that members of the ICU multidisciplinary team encounter in the delivery of end of life care to dying patients in ICUs.

METHOD

A scoping literature review was undertaken. Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus with full text, MEDLINE Complete and the EBSCOhost E-Journals Database were searched electronically to identify literature from April 2007 to April 2017, alongside hand-searching. Critical appraisal tools were used and thematic analysis was undertaken to analyse the data and identify themes.

FINDINGS

Ten articles were included in the literature review, which identified various challenges and facilitators in providing effective end of life care in ICUs. The main themes identified were: communication, family involvement, personal factors and the ICU environment.

CONCLUSION

All of the studies included in the literature review identified several important challenges related to communication, such as time constraints, disagreements among healthcare professionals, and a lack of knowledge among healthcare professionals about how to conduct challenging conversations with patients and families. Future developments in practice should consider the role of effective multidisciplinary team-working in end of life care.

Knowledge and Awareness of End-of-life Care among Doctors Working in Intensive Care Units at a Tertiary Care Center: A Questionnaire-based Study

INTRODUCTION

End-of-life care (EOLC) is an increasingly important concern in the management of terminally ill patients. Effective EOLC depends significantly on the physicians working in the critical care units. Thus, adequate knowledge of critical care professionals regarding EOLC is important. We conducted this study to evaluate the awareness and knowledge of doctors working in critical care units toward EOLC.

MATERIALS AND METHODS

Doctors working in critical care units were invited to fill paper-based questionnaire. The validated questionnaire was constructed based on the existing literature on EOLC and expert opinion. The questionnaire comprised four sections: demographic details, experience with EOLC situations, general awareness of EOLC, and specific awareness of EOLC in clinical practice. The collected data were analyzed by descriptive analysis.

RESULTS

Most respondents had not counseled more than five families regarding EOLC over 1 month. Majority of the respondents (81.7%) had heard of EOLC; the major source of information being their work in the concerned specialty. Only 29.2% of the respondents applied EOLC principles in their clinical practice. Main barriers were lack of information and training. Only 20.3% of the respondents were aware of Indian guidelines about EOLC. Majority of the respondents disagree regarding the usage of critical care units and resuscitation of terminally ill patients and were in favor of home care. One-third respondents felt uncomfortable in discussing EOLC issues with the families. Half of the respondents felt that they were only somewhat competent in managing EOLC issues. Most respondents opined that training and education in medical curriculum for terminally ill patients are lacking and were in strong favor of inclusion of specific training for the same.

CONCLUSION

The EOLC needs to be an integral part of critical care management and teaching curriculum. An integral referral system may also be an option for various advance disease patients getting treatment from critical care specialists for EOLC decision.

HOW TO CITE THIS ARTICLE

Agrawal K, Garg R, Bhatnagar S. Knowledge and Awareness of End-of-life Care among Doctors Working in Intensive Care Units at a Tertiary Care Center: A Questionnaire-based Study. Indian J Crit Care Med 2019;23(12):568-573.

Transitioning to Comfort-Focused Care at the End of Life

Shared decision making requires the exchange of information from the patient and the surgeon (and ideally involves the expertise of the entire multidisciplinary team) to determine the medical and/or surgical treatment that best aligns with the patient's goals and values. Should the surgical patient wish to transition to end-of-life care, the transition to comfort-focused care is within the scope of practice for surgeons. Incorporating the expertise of other health care professionals is an important consideration for whole-patient care. Integrating primary palliative care into surgical practice can help mitigate unnecessary suffering and allow a smoother transition to comfort-focused care.

Value, Chronic Critical Illness, and Choosing Wisely

Management of limited health-care resources has been of growing concern. Stewardship of health-care dollars and avoidance of low-value care is being increasingly recognized as a matter that affects all practitioners. This review aims to examine a particular pathological state with multifactorial origins: chronic critical illness (CCI). This condition exerts a large toll on society as well as individual patients and their families. Here, we offer a brief review as to the incidence/prevalence of CCI and suggestions for prevention. Emphasis should be placed on the importance of early, open communication among physicians and patients about their end-of-life decisions and advanced directives, so that decisions can be made wisely and with the patient's best interests in mind.

Dying in intensive care units of India: Commentaries on policies and position papers on palliative and end-of-life care

PURPOSE

This study critically examines the available policy guidelines on integration of palliative and end-of-life care in Indian intensive care units to appraise their congruence with Indian reality.

MATERIALS AND METHODS

Six position statements and guidelines issued by the Indian Society for Critical Care Medicine and the Indian Association of Palliative Care from 2005 till 2015 were examined. The present study reflects upon the recommendations suggested by these texts.

RESULT

Although the policy documents conform to the universally set norms of introducing palliative and end-of-life care in intensive care units, they hardly suit Indian reality. The study illustrates local complexities that are not addressed by the policy documents. This include difficulties faced by intensivists and physicians in arriving at a consensus decision, challenges in death prognostication, hurdles in providing compassionate care, providing "culture-specific" religious and spiritual care, barriers in effective communication, limitations of documenting end-of-life decisions, and ambiguities in defining modalities of palliative care. Moreover, the policy documents largely dismiss special needs of elderly patients.

CONCLUSION

The article suggests the need to reexamine policies in terms of their attainability and congruence with Indian reality.

Perspectives of Singaporean patients and caregivers towards quality of life or quantity of life with disease-modifying treatment in the end-of-life setting

Background:

Healthcare providers often struggle to balance the sometimes competing considerations of maximizing quality of life (QoL) and quantity of life with disease-modifying treatment (DMT). These decisions require in-depth dialog between all parties in order to understand the concerns and perspectives of the patient and caregiver in this period.

Objectives:

The objectives of this study were to explore Singaporean patients’ and caregivers’ attitudes towards QoL and DMT, and to examine the reasons behind their beliefs.

Methods:

Participants were given a video vignette of a family discussing how best to care for their mother who is recently diagnosed with cancer and were interviewed regarding their thoughts on QoL and DMT for a 70-year-old patient with stage IV metastatic cancer.

Subjects/Setting:

A total of 21 patients and caregivers were recruited from a tertiary oncology centre.

Results:

Both patients and caregivers show little support for pursuing QoL, despite the likely compromise to the patients’ QoL. These participants believed that not pursuing DMT was tantamount to giving up and accepting death. Whilst patients did accept that in some circumstances a QoL approach would be acceptable, caregivers remained adamant upon a DMT approach. The perspectives of caregivers reflected the influence of the Confucian-inspired practice of filial piety.

Conclusion:

Local sociocultural beliefs and values continue to play a significant consideration in end-of-life decision-making. However, compliance with these beliefs have evolved, with greater consideration given to clinical and QoL factors.

Conflicts between healthcare professionals and families of a multi-ethnic patient population during critical care: an ethnographic study

BACKGROUND

Conflicts during communication in multi-ethnic healthcare settings is an increasing point of concern as a result of societies' increased ethno-cultural diversity. We can expect that conflicts are even more likely to arise in situations where difficult medical decisions have to be made, such as critical medical situations in hospital. However, in-depth research on this topic is rather scarce. During critical care patients are often unable to communicate. We have therefore investigated factors contributing to conflicts between healthcare professionals and family members from ethnic minority groups in critical medical situations in hospital.

METHODS

Ethnographic fieldwork was done in one intensive care unit of a multi-ethnic urban hospital in Belgium over 6 months (January 2014 to June 2014). Data were collected through negotiated interactive observation, in-depth interviews with healthcare professionals, from patients' medical records, and by making notes in a logbook. Data were analysed by using grounded theory procedures.

RESULTS

Conflicts were essentially related to differences in participants' views on what constitutes 'good care' based on different care approaches. Healthcare professionals' views on good care were based predominantly on a biomedical care model, whereas families' views on good care were mainly inspired by a holistic lifeworld-oriented approach. Giving good care, from the healthcare professionals' point of view, included great attention to regulations, structured communication, and central decision making. On the other hand, good care from the families' point of view included seeking exhaustive information, and participating in end-of-life decision making. Healthcare professionals' biomedical views on offering good care were strengthened by the features of the critical care context whereas families' holistic views on offering good care were reinforced by the specific characteristics of families' ethno-familial care context, including their different ethno-cultural backgrounds. However, ethno-cultural differences between participants only contributed to conflicts in confrontation with a triggering critical care context.

CONCLUSIONS

Conflicts cannot be exclusively linked to ethno-cultural differences as structural, functional characteristics of critical care substantially contribute to the development of conflicts. Therefore, effective conflict prevention should not only focus on ethno-cultural differentness but should also take the structural organizational characteristics of the critical care context sufficiently into account.