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.