End of life (EOL) care has evolved in the last few decades, driven by the creation and use of multiple lifesaving technologies. These technologies, while enabling us to keep patients alive who otherwise would have died, will not often cure the patient’s illness thus placing the burden of deciding when to use such therapies on doctors and patients. These decisions necessitate a balance between relying on sole input from the medical team (paternalism) and exclusively honoring the patient’s rights to decide on medical care (autonomy).
Other key aspects of EOL care in the ICU include: accurate prognostication and using substituted judgment for determining goals of care for patients who cannot decide for themselves. Advanced technologies have made our ability to predict death even more difficult since there is almost always a salvage therapy that may be employed to prolong life but at great cost (the patient’s physical and mental independence, financial strain and family care-taker burden to name a few). It is becoming clear that established terms such as “Do Not Resuscitate” (DNR) and “medically futile” are no longer useful concepts as these definitions are far too subjective and inconsistent in common practice. When crafting a care plan for a critically ill patient, deciding on the terminology to use when communicating the plan to the care team and discussing the situation with family is often complicated. This process relies as much on patient (and doctor) personal life preferences and beliefs as it does on medical science. Relying on someone other than the patient to make EOL decisions introduces even more complexity as it presents another threshold of evaluation: that of determining who is an appropriate surrogate decision maker. Finally, multiple studies have shown that a variety of practices can be used to make the dying process better for patients and families.
End of life (EOL) Futility Prognostication ICU Do not resuscitate (DNR) Dying Ethics Shared decision making Autonomy Surrogate decision making
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