Critical care clinics
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Critical care clinics · Jul 2004
ReviewCommunicating about end-of-life care with patients and families in the intensive care unit.
Discussing end-of-life care and death with patients and their families is an extremely important part of providing a good quality care in the intensive care unit (ICU). Although there is little empiric research to guide ICU clinicians in the most effective way to have these conversations, there is a developing literature and experience and an increasing emphasis on making this an important part of the care we provide. Much like other ICU procedures or skills,providing sensitive and effective communication about end-of-life care requires training, practice, and supervision, as well as planning and preparation. Although different clinicians may have different approaches and should change their approach to match the needs of individual patients and their families, this article reviews some of the fundamental components to discussing end-of-life care in the ICU that should be part of the care of patients with life-threatening illnesses in the ICU.
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Family's needs and considerations are an essential component of intensive care unit (ICU) care. Family satisfaction is related to clinician communication and decision making. Indeed, timely, honest communication is vital to the psychosocial health and satisfaction of the family. ⋯ Again, good communication skills are critical to family satisfaction with decision making and comfort with the care received. Family members have numerous psychosocial changes, and may experience depression,anxiety, or anticipatory grief while their family member is dying in the ICU. Awareness of these conditions, providing support to the families, and allowing family access to the dying individual can assist with meeting the family's desire to see their family member have a peaceful death.
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Critical care clinics · Jul 2004
ReviewPalliative care in the intensive care unit: barriers, advances, and unmet needs.
The concept that critical illness and terminal illness are necessarily distinct entities has given way to the understanding that they often exist on the same spectrum. Consequently, there is growing consensus that palliative treatment must coexist with attempts at restorative treatment in the intensive care unit (ICU). Palliative care in the ICU has evolved from a relatively one-dimensional construct of terminal sedation in dying patients to a multidisciplinary field addressing symptom control, physician-patient-family communication,spiritual needs, and the needs of health care providers. As ongoing research efforts yield new insights, our ability to practice evidence-based palliative care in the ICU will grow, and new avenues for improvement will become evident.
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Critical care clinics · Jul 2004
ReviewPrinciples and practice of withdrawing life-sustaining treatments.
The clinician's responsibility to the patient does not end with a decision to limit medical treatment, but continues through the dying process. Every effort should be made to ensure that withdrawing life support occurs with the same quality and attention to detail as is routinely provided when life support is initiated. ⋯ Key steps in this process are identifying and communicating explicit shared goals for the process, approaching withdrawal of life-sustaining treatments asa medical procedure, and preparing protocols and materials to assure consistent care. Our hope is that adopting a more formal approach to this common procedure will improve the care of patients dying in intensive care units.
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Critical care clinics · Jul 2004
ReviewValue and role of intensive care unit outcome prediction models in end-of-life decision making.
In the United States, intensive care unit (ICU) admission at the end of life is commonplace. What is the value and role of ICU mortality prediction models for informing the utility of ICU care?In this article, we review the history, statistical underpinnings,and current deployment of these models in clinical care. We conclude that the use of outcome prediction models to ration care that is unlikely to provide an expected benefit is hampered by imperfect performance, the lack of real-time availability, failure to consider functional outcomes beyond survival, and physician resistance to the use of probabilistic information when death is guaranteed by the decision it informs. Among these barriers, the most important technical deficiency is the lack of automated information systems to provide outcome predictions to decision makers, and the most important research and policy agenda is to understand and address our national ambivalence toward rationing care based on any criterion.