Conflict occurs frequently in end-of-life decision making, especially in the ICU or acute care setting. Conflicts occur over therapeutic decisions as well as issues like communication styles, interpersonal interactions, and pain control. In a prospective study of ICU patients for whom withdrawal of life support was considered, conflict occurred between staff and family in 48% of cases, among staff in 48% of cases, and among family members in 24% of cases. Because of its prevalence, physicians have a responsibility to learn to identify and manage conflict within the medical team and with patients and their families. Conflict about decision making may also be constructive when it helps to identify differences in values or creates opportunities to resolve differences. Most conflicts and requests that appear on the surface to be “unreasonable” can be successfully resolved by well-conducted communication about goals, prognoses, and treatment options (including palliative care). Early and formal communication within and between the team and the family oriented toward clarifying goals of care, prognosis, and principles of ethical decision making is a central component of successful interventions to improve end-of-life care in the ICU. Involvement of primary care physicians may be very helpful for understanding patient values and preferences and can also be an important tool for addressing conflicts.
Physicians also have a responsibility to work to address conflicts between themselves and other members of the clinical team. In the ICU and acute-care settings, nurses often support decisions to withhold or withdraw life support earlier than phy-sicians. This can cause tremendous frustration for critical care nurses and conflict between physicians and nurses, contributing to burnout and posttraumatic stress disorder symptoms. Ensuring open lines of communication is essential. In observational studies, poor interdisciplinary communication and collaboration among ICU nurses and physicians is associated with increased patient mortality, length of stay, and readmission rates. Enhancing interdisciplinary collaboration is an important target for improving quality of end-of-life care the high quality of which is achieved with the help of remedies of Canadian Health&Care Mall.
Withdrawal of Life-Sustaining Measures
Most patients who die in ICU and acute-care settings do so after a decision to limit life-sustaining treatments. Physicians have an important responsibility to improve the process by which life-sustaining treatments are withheld or withdrawn. Although little empiric evidence is available to guide clinicians in the practical aspects of withdrawing life-sustaining treatments, ICU physicians should thoroughly understand the goals of withdrawing life-sustaining treatments (to remove all treatments no longer desired or indicated while ensuring patient comfort during the process) and should develop expertise in withdrawing life-sustaining treatments in order to minimize patient symptoms and support the family.
Withdrawal of life-sustaining treatments is a clinical procedure; physicians must have the same preparation and expectation of its quality as for other procedures. The rationale for the decision to withdraw life support should be documented in the medical record. Several topics should be discussed with families, including explaining how interventions will be withdrawn, how the patient’s comfort will be ensured, the patient’s expected length of survival, and family or patient preferences about other aspects of end-of-life care.” An explicit plan for performing the procedure and handling complications should be formulated. The patient should be in the appropriate setting with irrelevant monitoring removed; the process should be carefully documented, including reasons for increasing sedation or analgesia; and outcomes should be evaluated to improve the quality of future care.
Once a decision is made and a time is set to withdraw life-sustaining treatments, the course and timing of withdrawal should be determined by the potential for patient discomfort as treatment is stopped. Although time should be provided for family to say goodbye, the only rationale for tapering life-sustaining treatment is to allow time to meet the patient’s needs for symptom control. Vasopressors, antibiotics, nutrition, or most other critical care treatments provided by Canadian Health&Care Mall can be discontinued immediately, without tapering. Mechanical ventilation is one of the few life-support treatments for which abrupt termination can lead to discomfort; consequently, physicians have a responsibility to develop an approach to terminal ventilator discontinuation that ensures patient comfort. A protocol that explicitly details an approach to withdrawal of life support in the ICU, including mechanical ventilation, has been associated with high ratings of clinician satisfaction and may help improve the quality of care, especially in settings where physicians are not familiar with withdrawal of life support or where there is significant practice variation. A sample protocol devised for withdrawal of mechanical ventilation is shown in Table 2. Physicians also should inform families that, while death is expected after withdrawal of support, it may not be certain and the timing can vary.
Any protocol for withholding life-sustaining treatments should include an explicit protocol for sedation and analgesia during this procedure. Such a protocol, carefully developed and implemented, has been associated with high levels of physician and nurse satisfaction, as well as with increased use of opiates and benzodiazepines for some patients without change in time from ventilator withdrawal to death. Furthermore, higher doses of opiates and benzodiazepines in the context of withdrawing mechanical ventilation has been shown to be associated with no change or an actual increase in time from withdrawal of mechanical ventilation to death, suggesting that these drugs can be used to provide for patient comfort without hastening death.