New horizons (Baltimore, Md.)
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End-of-life decisions in the ICU are often complex and emotionally charged. Intensivists can correct the physiologic abnormalities of acute and chronic illness with drugs and technology, and prolong life in many situations. ⋯ Studies on do-not-resuscitate orders, and advanced and delayed directives comprise a portion of this work. This article contains a brief summary of selected research evidence on these difficult end-of-life issues.
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Troubling aspects of the experiences of patients at the ends of their lives have fueled interest in special benefits or privileges for this group. There is a presumption that being "at the end of life" is discernible. This study examines this presumption using data from two previously collected databases: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) and the Acute Physiology and Chronic Health Evaluation III (APACHE III). ⋯ Median prognostication estimates were not much different when given by physicians and were only a little more pessimistic in APACHE (median estimate for hospital survival on the day before death was .14 and 7 days before was .45). To make plans about care and to optimally support most dying persons and families, conversations must occur while the patient still has a considerable chance of surviving the current episode of illness. Using statistical estimates of prognosis to designate a category of "terminally ill" patients for public policy purposes is unavoidably arbitrary, will often be contested, and will have differential effects upon those dying with differing diseases.
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The withholding and withdrawal of life support are processes by which various medical interventions either are not given to or are taken away from patients, with the expectation that they will die as a result. The propriety of withholding and withdrawal of life support has been supported by ethical statements from groups such as the Task Force on Ethics of the Society of Critical Care Medicine, and by a series of legal decisions beginning with the Quinlan case. ⋯ Observational studies show that: withholding and withdrawal of life support occur frequently, the frequency has increased over the past several years in some ICUs, patients and families generally agree with physician recommendations to limit care or request such limitation, disagreements sometimes occur on this issue, withdrawal of life support occurs more commonly than withholding of life support in most ICUs, cardiopulmonary resuscitation is the therapy most frequently withheld, mechanical ventilation is the therapy most frequently withdrawn, this withdrawal process usually is gradual, and it usually is facilitated by the administration of sedatives and analgesics. Clinical information such as this is helping to define a standard of care in the area of withholding and withdrawal of life support.
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Critical care physicians are frequently called on to negotiate issues of medical management with patients, their families, and other physicians. These decisions frequently revolve around end-of-life care. Recent data suggest that such discussions are manageable. ⋯ Since the alternative to aggressive ICU care is usually the death of the patient, it seems difficult to reconcile a physician's refusal to treat with patient autonomy. The concept of a fiduciary offers a model of the physician-patient relationship in which the physician commits himself to the patient's best interests but retains a role in defining those interests. This model offers significant benefits over medical futility in negotiating conflicts over end-of-life care.
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Healthcare reform continues to move forward, with the influence of managed care increasing in most areas of the United States. Strategies for cost containment are being considered to limit marginally beneficial health care, including futile-care policies, capitation, preset limits on health care, and guidelines for writing do-not-resuscitate (DNR) orders. Recent studies which attempted to improve communication between patients and physicians have failed to improve the quality of end-of-life care offered by healthcare providers. ⋯ Moreover, approximately 0.5% of all ICU care could be limited should DNR orders be written earlier in a patient's hospital or ICU stay. In addition, a shift from open-format ICUs to semiclosed units managed by qualified critical care physician directors would reduce the number of patients with futile or failed cardiopulmonary resuscitation, and increase the number of patients having care withheld or withdrawn after failed ICU therapy. Such a change would result in more substantial savings.