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-oflife 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 endof-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. (Crit Care Med 2008; 36:953‐963)

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Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine

Objective:To explore registered nurses’ and attending physicians’ perspectives on caring for dying patients in intensive care units (ICUs), with particular attention to the relationships among moral distress, ethical climate, physician/nurse collaboration, and satisfaction with quality of care.Desig

Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate.

Purpose To determine whether the place of death for patients with cancer is associated with patients' quality of life (QoL) at the end of life (EOL) and psychiatric disorders in bereaved caregivers. Patients and Methods Prospective, longitudinal, multisite study of patients with advanced cancer and their caregivers (n = 342 dyads). Patients were followed from enrollment to death, a median of 4.5 months later. Patients' QoL at the EOL was assessed by caregiver report within 2 weeks of death. Bereaved caregivers' mental health was assessed at baseline and 6 months after loss with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the Prolonged Grief Disorder interview. Results In adjusted analyses, patients with cancer who died in an intensive care unit (ICU) or hospital experienced more physical and emotional distress and worse QoL at the EOL (all P ≤ .03), compared with patients who died at home with hospice. ICU deaths were associated with a h...

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Place of Death: Correlations With Quality of Life of Patients With Cancer and Predictors of Bereaved Caregivers' Mental Health

Introduction Chronic diseases have assumed an increasingly important role in public health research and intervention. Without treatment, depressive disorders characteristically assume a chronic course and are expected, by 2020, to be second only to heart disease in the global burden of disease. Thus, understanding the relationship between depressive disorders and chronic disease appears vital to public health assessment and health care delivery. Methods Articles for review were primarily identified by a Medline search emphasizing the subject headings mental disorders or depression crossed with selected chronic diseases and conditions including asthma, arthritis, cardiovascular disease, cancer, diabetes, and obesity. Results Mental illnesses - most specifically, depressive disorders - were associated with increased prevalence of chronic diseases. This association between depression and chronic disease appears attributable to depressive disorders precipitating chronic disease and to chronic disease exacerbating symptoms of depression. The complex interrelationship between depressive disorders and chronic disease has important implications for both chronic disease management and the treatment of depression. Conclusion Depressive disorders assume an important role in the etiology, course, and outcomes associated with chronic disease. Multivariate community-based research and intervention fostering the detection and treatment of depressive disorders is needed, as is further examination of the role exerted by mental illnesses other than depression in the pathogenesis of chronic disease.

The vital link between chronic disease and depressive disorders.

Each year, 500,000 children in the United States cope with life-threatening illness. These children and their families require comprehensive, compassionate, and developmentally appropriate palliative care. This review article discusses pediatric palliative care, which should intersect with the aims of curing and healing and become instrumental for improving quality of life.

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Pediatric palliative care.

Objective To characterize the symptom experience of a cohort of intensive care unit (ICU) patients at high risk for hospital death. Design Prospective analysis of patients with a present or past diagnosis of cancer who were consecutively admitted to a medical ICU during an 8-month period. Setting Academic, university-affiliated, tertiary-care, urban medical center. Patients One hundred cancer patients treated in a medical ICU. Intervention Assessment of symptoms. Measurements Patients’ self-reports of symptoms using the Edmonton Symptom Assessment Scale (ESAS), and ratings of pain or discomfort associated with ICU diagnostic/therapeutic procedures and of stress associated with conditions in the ICU. Main Results Hospital mortality for the group was 56%. Fifty patients had the capacity to respond to the ESAS, among whom 100% provided symptom reports. Between 55% and 75% of ESAS responders reported experiencing pain, discomfort, anxiety, sleep disturbance, or unsatisfied hunger or thirst that they rated as moderate or severe, whereas depression and dyspnea at these levels were reported by approximately 40% and 33% of responders, respectively. Significant pain, discomfort, or both were associated with common ICU procedures, but most procedure-related symptoms were controlled adequately for a majority of patients. Inability to communicate, sleep disruption, and limitations on visiting were particularly stressful among ICU conditions studied. Conclusions Among critically ill cancer patients, multiple distressing symptoms were common in the ICU, often at significant levels of severity. Symptom assessment may suggest more effective strategies for symptom control and may direct decisions about appropriate use of ICU therapies.

Erwin Oei

Papers

Self-reported symptom experience of critically ill cancer patients receiving intensive care.