Guidelines for end of life care in icu

Guidelines for End of Life Care in ICU lecture , Egyptian College of Critical care Physicians Knowledge Corner

1. Guidelines for End of Life Care in ICU
Dr. Emadeldin Omar Abdelaziz, BSc, MSc, MD
Ass. Professor of Critical Care, Cairo University

2. “Dying can be a peaceful event
or a great agony when it is
inappropriately sustained by life
support.” Roger bone

3. Introduction
A significant number of patients die in hospital, & many of them
are shifted to ICUprior to death
When all medical treatment including life-supporting
interventions in ICU appears to be futile &unlikely to restore
patient, death is delayed at high psychological, social, & financial
costs for all parties (patient, family, & health professionals)
The primary ICU purpose should not only to promote aggressive
treatment; but also help patients & families tomake wise end-of-
life decision

4. Full Treatment
(Diagnostic & Therapeutic Strategies)
Comfort Care
two ends of the continuum of care of a patient with a life-threatening
illness.
Both are appropriate at different points in the patient’s disease
process

5. The continuum of palliative care in an illness
trajectory
•

6. End of Life Care

7. Definition
End-of-life careis a multidisciplinary teamapproach
to a terminally ill patient that shifts the focus of care to
symptom control, comfort, dignity, quality of life, and
quality of dying rather than treatments aimed at cure
or prolongation of life

8. Objectives of End of Life Care
•To achieve a “good death” for any dying person,
irrespective of the situation, place, diagnosis, or
duration of illness

9. Principles of Good Death
Ability to know when
the death is
approaching
Well control of
physical symptoms
and nonphysical
needs have to be met
Right to die in a
dignified manner at
the place of choice,
without unnecessary
life prolongationwith
artificial means

10. Infrastructural requirements for good end-of-
life care
•Presence of guiding hospital policy
•Awareness and implementation of policyPolicy
•Specially allocated area in the hospital, that ensures privacy
•Round -the -clock staffSpace & staff
•Education to all involved healthcare professionals, on end-of-
life care
•Hands on training and mentorship to junior staff
Education &
training
•End-of-life care pathway (structured and tailor made to suit
individual health care setup).
•Standardized forms on withholding and withdrawing life support
Documentation

11. Ethical issue
Autonomy
•to respect patient’s choices and
preferences.
Autonomy
•to respect patient’s choices and
preferences.
Beneficence
•to act always in patient’s best
interests.
Beneficence
•to act always in patient’s best
interests.
Non-maleficence
•todo no harm.
Non-maleficence
•todo no harm.
Distributivejustice
•toprovide treatment & resources to
one with potentially curable
condition over another for whom
treatment will be futile
Distributivejustice
•toprovide treatment & resources to
one with potentially curable
condition over another for whom
treatment will be futile
Four fundamental
principles
Four fundamental
principles

12. Initiation End of Life Care

13. When to initiate end-of-life (EOL)
discussions?
1. Advanced age
coupled with poor
functional state due to
one or more chronic
debilitating organ
dysfunction
2. Acute
catastrophic
illnesses with
organ
dysfunctions
unresponsive to a
reasonable period
of aggressive
treatment
3. Coma (in the
absence of brain
death) due to
acute catastrophic
causes with non
reversible
consequence
4.Post-
cardiorespiratory
arrest with poor
neurological
recovery after at
least 3 days

14. When to initiate end-of-life (EOL)
discussions?
5. Chronic severe
neurological
conditions with
advanced
cognitive &/or
functional
impairment.
6. Brain dead non
organ donor
7. Progressive
metastatic cancer
where treatment
has failed, or
patient has refused
treatment
8. Patients with
decision-making
capacity with
DNAR Code.

15. When to initiate end-of-life (EOL)
discussions?
•identification of this subset of population is essential to prevent any
medical futility (medically inappropriate)
•Patients, families, & healthcare providers should be educated about
appropriateness of ICU admission, nature of ICU interventions including
resuscitation, outcomes and futility of these interventions, and detailed
information on alternatives to ICU admission.

16. Guidelines for End-of-Life Care Process

17. Guideline 1 Physician’s objective & subjective
assessment of medical futility & the dying process
Practice
The above list to start EOLD helps to
recognize medical futility & dying patient.
However, these points shouldn't be used in
isolation, but in the context of the clinical
status and condition of the patient.
Whenever there is doubt about the prognosis,
the physician shouldn't take any hasty
decisions, but wait for the disease process to
be more clear
Rationale
Recognizing medical futility & identifying the dying process is the first step toward
planning & delivering effective EOLC

18. Guideline 2 Consensus decisions among all medical team
about the poor prognosis & plan to initiate EOLC
discussion
Practice
If there’s difference in opinion regarding
prognosis, plan of EOLC should be
deferred, & reviewed again.
No member of the team should address
the family individually regarding the
prognosis until a consensus is reached
among all the team.
Rationale
To prevent any conflicting or inconsistent messages about the patient’s prognosis
going out to the patient’s family

19. Guideline 3 Honest, accurate & early disclosure of
prognosis to the family or capable patient
Practice
•Identify early a surrogate decision-maker for the patient for regular
communication
•Use understandable language for the family
Rationale
Moral & legal obligation to disclose to the family, with honesty & clarity, the
poor prognosis, the imminence of death, & that aggressive support may be futile

20. Guideline 4 Discussion & communication of
modalities of end-of-life care with the family
Rationale
This will help in the process of reaching a consensus through shared decision-making
Standard modalities as
•DNAR: no intubation, no CPR
•Withholding of life support/no escalation order: not to institute new treatment or escalate
existing life support modalities
•Withdrawal of life support : cessation and removal of an ongoing medical therapy, & not to
substitute an equivalent or alternative treatment

21. Guideline 5 Shared decision-making consensus via
open & repeated discussions with the family
Practice
If there is conflict with the family/patient, the
physician must continue all existing life
supporting interventions until reaching a
consensus.
Conflict can be resolved by improved
communications, seeking second opinions, &
psychologist’s consultation, seeking the help
of other senior physicians or hospital’s Ethics
Committee.
Rationale
respect to the patient’s autonomy in making an informed choice, while fulfilling his obligation
of providing beneficent care.

22. Guideline 6 Transparency & accountability
through accurate documentation
Practice
Documentation should include details of
discussion, the final decision, the specific
modalities withheld or withdrawn and the
comfort strategies planned.
Life support limitation form should be signed
by 2 of the family and the medical team
Rationale
Evidence of evolving decision-making process that indicates appropriate care, ensures that the
patient is informed of all the available options & that overall care plan was explained to him.

23. Guideline 7 Ensure consistency among medical
team
Practice
The bedside nurse can play an important role in ensuring that there is consistency
among all caregivers in following the care plan.
Rationale
This will avoid any unnecessary therapeutic interventions, make the team focus on
comfort measure and family support and have consistency in communication with the
family

24. Guideline 8 Implementing the process of
withholding/withdrawing life support
Rational
Life off pain and distress and avoid the agony and burden of a prolonged dying
process through life support interventions,
So, appropriate use of pharmacologic therapy, depending on prevailing levels of
analgesia and sedation at the time of EOLC decisions, should be individualized
and used to ensure that the patient is always pain-free and comfortable

25. Guideline 8 Implementing the process of
withholding/withdrawing life support
Practice
Preparation
* Environment -quiet and comfortable
* Patient-comfortable position
* Family -No visiting restrictions ,honor requests for cultural and religious
rituals and discussing what is likely to happen during the dying process.
* Medical team-to review (LSTs) are being provided now and suitable order
of withdrawal.

26. Guideline 8 Implementing the process of
withholding/withdrawing life support
Practice
* Adequate sedation is achieved before any anticipated discomfort arises (SAS
<2)
•* the following order of withdrawal usually makes sense:
Stop unnecessary monitoring (e.g., Oximetry), devices (e.g., feeding tubes),
blood tests
Intermittent therapies (antibiotics, hemodialysis)
nutrition
Continuous therapies that maintain circulation (pressors, pacers, ECHMO,
LVAD, IABP)
Ventilator

27. Guideline 9 Effective & compassionate
palliative care to patient & appropriate
support to the family
Rational
* Good control of pain and physical symptoms.
* Preferred place of care should be respected and prepared
* Care givers should feel involved, supported, empowered and satisfied
* Family -prepared, educated, and feel supported about EOLC provision &
providers to be accepting and anticipating that patient is dying and willing to
provide EOLC

28. Guideline 9 Effective & compassionate
palliative care to patient & appropriate
support to the family
Practice
* Relief of EOL symptoms such as pain, dyspnea, delirium, and respiratory
secretions
* Review & stop unnecessary medication or investigations.
* Continued communication throughout the process
* Psychosocial support to patient, family, and caregivers
* Meeting special family requests (religious/spiritual/cultural).

29. Guideline 10 After death care
Rational
it begins with communicating the news of
the death to the family in early and a
sensitive manner. The news should be
communicated in a calm and private
environment.
It is essential to take inputs from the
family regarding after death rituals.
Culturally appropriate and sensitive after death care must be provided
to all dying patients irrespective of the situation or the setting

30. Guideline 11 Bereavement care support
Rational
Bereavement support to the family should begin before patient’s death.
Families & caregivers who are at high risk for bereavement are identified &
are prepared for patient’s death.
In bereavement phase, care givers with bereavement symptomatology are
identified & managed with the help of medical social workers, clinical
psychologists, and psychiatrist
End-of-life care does not stop at death but continues even after death.
Bereavement care helps family/medical team to cope with grief and other issues

31. Guideline 12 Review of care process
Rational
Quality of EOLC provided should be reviewed on a case-by-case basis by the
multidisciplinary team who provided the care and the series should be audited
periodically with the help of external auditors. Review will help to
* bridge gaps in care process
* understand the family’s perception of the care provided
* improvethe EOLC process

32. Future Directions

33. Education and Practice
The concepts of medical futility, recognition of the dying
patient, palliative care, & providing good death must be an
integral part of the curriculum in undergraduate &
postgraduate medical courses
The critical care society and other like-minded
organizations and experts must develop educational
modules and workshopsfor practising physicians

34. Education and Practice
Legislative framework
•In Egypt, legal guidelines and provisions clarifying
moral/ethical dilemmas around EOLD do not exist at
present
Social culture modification.

35. Reserach
Research in Egypt in this expanding field of healthcare has been
negligible.
Empirical data on EOL and palliative care need to be generated
for Egypt.
The unique barriers to EOLC in its sociocultural & political
context should be better understood through research. Measures
to overcome these barriers should be defined through appropriate
interventional studies.

36. References
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2019
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37. Questions? Comments?