Dying with Dignity in the Intensive Care Unit

The New England Journal of MedicineDeborah Cook, MD, and Graeme Rocker, DM

LSU Internal Medicine Journal ClubJaclyn Spiegel MD, PGY3

September 18, 2014

Background and Research Question

• 1 in 5 deaths in the United States occurs in the ICU• What does it mean to “die with dignity”?

– Recognizes human worth and emphasizes physical comfort, autonomy, meaningfulness, preparedness, communication

• Understanding the patient and his/her needs as a person in the setting of depersonalizing devices

• How can we as physicians best serve our patients and their surrogates at the end of life?– Palliative care in the critical care setting

Study design

• Review of 50 critical care articles which addressed aspects such as epidemiology of death in the ICU, caregiver burden, bereavement, surrogate decision-making, withdrawal of mechanical ventilation, family satisfaction, family interpretation of prognostic discussions, varied cultural views of the dying process, etc

Recommendations

• Adherence to 7 key domains for quality improvement at the end of life:1. Patient- and family-centered decision-making2. Communication3. Continuity of care4. Emotional and practical support5. Symptom management6. Spiritual support7. Emotional/organizational support for ICU clinicians

1. Family-centered decision-makingThe Effective Family Conference

• Value/appreciate what family members say• Acknowledge family members’ emotions• Listen to their concerns• Understand who the patient was in active life • Elicit questions from the family members

– Led to less non-beneficial interventions– Family members were less negatively affected by the experience post-

mortem• Less anxiety• Less depression• Less PTSD symptoms

2. CommunicationSurrogate Preferences

• The power of silence– Increased satisfaction with family meetings where physicians talked less and

listened more• Prognostic statements

– No preference regarding if prognosis was relayed qualitatively (“very low chance of survival”) versus quantitatively (“10% chance of survival”)• Optimism bias • Rectify this with the notion of “hoping for the best but preparing for the worst”

• Physician recommendations regarding life support– 56% preferred to hear physicians’ recommendations– 42% preferred NOT to have recommendations– 2% indifferent

3. Continuity of Care

• Keeping in mind that at the time of critical illness, most patients and surrogates are communicating with an unfamiliar clinician at the time of most vulnerability

4. Emotional/practical support

• Including chaplains in care team• Ethics consultants to help with conflict

resolution– Reduced duration of non-beneficial treatments

5. Symptom ManagementConsiderations when Withdrawing Life Support

6. Spiritual SupportTaking a Spiritual History

• Spiritual belief system• Personal spirituality• Integration with a spiritual community• Ritualized practices and restrictions• Implications for medical care• Terminal-events planning

7. Emotional/organizational support for ICU Clinicians

• Vicarious traumatization from dealing with repeated sadness and loss

• Awareness of the effects of “compassion fatigue”

Study Limitations

• Assumes that there are no conflicts between the ICU team and the patient’s family

• Assumes that patients have had true relationships/rapport with their surrogates and that surrogates are acting in a way that is not conflicting with patient’s desires

• Assumes that patient indeed has a surrogate decision-maker