What are the key considerations for end of life care in critical care settings?

Key Considerations for End-of-Life Care in Critical Care Settings

Early integration of palliative care for patients at high risk of mortality in the ICU is essential to improve quality of life, enhance alignment with patient goals, and provide comprehensive symptom management. 1

Symptom Management

• Regular assessment and management of pain, dyspnea, and depression should be conducted using standardized validated tools for all critically ill patients approaching end of life 1
• Strong evidence supports the use of opioids for unrelieved dyspnea and pain management in end-of-life care, with no evidence that properly titrated opioids cause premature death 1
• Oxygen therapy should be considered for short-term relief of hypoxemia in patients with advanced cardiopulmonary disease 1
• Thirst, anxiety, fatigue, delirium, and sleep disturbances should be routinely evaluated and documented using validated assessment instruments 1

Decision-Making Process

• Structured end-of-life decision-making strategies improve staff satisfaction and decrease mental health symptoms in healthcare providers 1
• Early identification of patients who could benefit from palliative approaches should be based on individual patient symptoms and preferences rather than rigid criteria 1
• Advance care planning should include trained facilitators (including palliative care specialists), involve key decision makers, and address care across settings 1
• Decision-making should respect patient autonomy and preferences while considering ethical principles, legal frameworks, and cultural norms 1

Communication and Family Support

• Communication training for ICU staff and printed communication aids for families improve outcomes and satisfaction 1
• Structured family conferences with clear, compassionate communication about prognosis and goals of care reduce family anxiety and improve satisfaction 1
• Families should receive continuous emotional support and frequent opportunities to voice wishes and concerns throughout the end-of-life process 1
• Culturally sensitive interventions should be implemented to address racial and socioeconomic disparities in end-of-life care 1

Interdisciplinary Collaboration

• Integration of palliative care specialists for complex cases improves quality of life and enhances alignment with patient goals 1, 2
• Early palliative care consultation (within 3 days of ICU admission) for high-risk patients can reduce ICU length of stay and improve patient satisfaction 1
• Collaboration between emergency/trauma surgeons and palliative care teams is essential to support complex end-of-life decision making 1
• Interdisciplinary coordination helps provide holistic care addressing physical, emotional, psychological, and spiritual needs 1

Caregiver Support

• Healthcare providers should routinely screen caregivers for practical and emotional needs while caring for a patient near the end of life 1
• Evidence suggests that individualized multicomponent interventions may be more beneficial than limited caregiver interventions 1
• Supporting families through the initial stages of grieving is an essential component of end-of-life care in the ICU 1
• Hospital-based palliative care consultative services have been associated with improved after-death family satisfaction 1

Common Pitfalls and Challenges

• Delayed transition to end-of-life care can negatively impact patient and family experiences; timely shifting to appropriate care improves outcomes 1
• Starting or continuing non-beneficial life-sustaining treatments that merely prolong the dying process is associated with moral distress among ICU healthcare providers 1
• Inadequate symptom management, particularly of pain and dyspnea, significantly diminishes quality of dying 1
• Conflicts related to end-of-life decisions are common and often stem from value differences between patients, families, healthcare professionals, and institutions 3
• Racial and socioeconomic disparities exist in hospice utilization, with Asian, African American, and Hispanic patients receiving less hospice care than Caucasian patients 1

Special Considerations for Specific Populations

• For elderly trauma patients, early palliative care consultations have been associated with improved secondary outcomes such as reduced length of hospital stay 1
• In patients with advanced dementia, palliative care may be the most appropriate strategy, focusing on quality of life, dignity, and comfort rather than aggressive medical interventions 4
• For patients with respiratory diseases, pulmonary rehabilitation, facial cooling (by use of fan), anxiolytics, and opioids may help manage dyspnea 1
• In patients with cancer, nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates are effective for pain management 1