While prevention of premature death has always been a primary goal of medicine, provision of a comfortable and peaceful death has been widely acknowledged as an important end in itself only in the last several decades. Even with widespread professional acknowledgment of the importance of palliative care, many patients die in moderate or severe pain, physicians are often unaware of patients’ wishes regarding end-of-life care, and interventions are often inconsistent with patients’ preferences. Providing high-quality end-of-life care is difficult and complex. Figure 1 shows the diverse skill set necessary for providing high-quality end-of-life care, as derived from the perspectives of patients with chronic and life-limiting illnesses, family members, physicians, and nurses.
In this review, we describe the responsibilities of pulmonary and critical care physicians in providing end-of-life care to patients and their families. Although many of these responsibilities are common to all physicians caring for patients with life-limiting illness, we focus on issues most relevant to pulmonary and critical care settings. We also focus on practical aspects of providing this care, such as prognostication and decision making about goals of care suggested by Canadian Health Care Mall, approaches to communicating with patients and family, the importance of interdisciplinary collaboration and addressing conflicts, principles of withholding and withdrawing life sustaining measures, and the role of cultural competency in end-of-life care.
End-of-life care is frequently cited as an area of particular relevance to medical professionalism, both in concert with and in addition to medical ethics. Perhaps never more than in dealing with end-of-life issues will the physician’s culture, spiritual beliefs, and personal values influence decision making and therefore have the potential to compromise or test professionalism. The hospital setting, and particularly the ICU setting, compounds these challenges to physicians’ professionalism. The ICU setting, a strange, stressful, and often seemingly hostile environment to patients and families, increases vulnerability to the opinions, influences, or preferences of clinicians. Variable and conflicting approaches to care may be more pronounced and more common than in other health-care settings. In the context of these challenges, maintaining awareness of one’s personal values and simultaneously understanding and respecting the values of others becomes especially important. The key components of professionalism, including respect, integrity, honesty, and compassion, provide a foundation for the skills needed to provide competent and compassionate care at the end of life.
Figure 1. Conceptual model of the domains of physicians’ skills at providing high-quality end-of-life care based on analyses of focus group transcripts.