Providing End of Life Care in the ICU
Critical Care Nurses have an important and integral contribution to make in the provision and enhancement of end-of-life (EOL) care through their varied roles. Due to the fact that end-of-life care is emerging as a comprehensive area of expertise in ICU, these contributions can be provided through direct practice, research, education, administration and policy. EOL care demands the same level of knowledge and competence as all other areas of ICU practice (Truog). CACCN endorses the Canadian Nurses Association (CNA) position statement on “Providing Nursing Care at the End of Life”. End-of-life care is rooted in the CNA’s Code of Ethics for Registered Nurses. The code endorses that nurses strive to foster comfort, alleviate suffering, provide adequate pain and symptom relief, and support a dignified and peaceful death.
CACCN endorses that the following factors are essential for nursing practice for patients who must spend their final days in the ICU environment:
- Every patient and their significant others as defined by the patient have a right to information about prognosis and the benefit of interventions. The term “benefit” may range along a continuum from significant, uncertain to no benefit.
- The provision of knowledge regarding prognosis and benefit of interventions allows the patient and family to make informed decisions about the suitable course of action, including when applicable, the withdrawal or withholding of life support.
- Frequent, clear, understandable, consistent and updated information must be provided as close as possible to admission and throughout the course in critical care in order enhance mutual trust and diminish the possibility of conflict. A holistic approach to the provision of care, focused on continuity, comfort, and palliation, assists the patient and family to feel supported.
CACCN endorses that both healthcare institutions and provincial associations have a responsibility in directing the process of the provision of end-of- life care.
- Nurses in critical care need opportunities through education and mentoring to develop their competency in providing end-of-life care around the areas of: communications skills to advocate for patients and families, standardized approaches to pain and symptom management and seeking and providing emotional support to patients, families and members of the health care team including the nurse.
- Health care institutions need to develop policies and procedures to support the critical care nurse in the provision of end-of-life care. These processes should be developed in conjunction with the critical care nurse, collaborative interprofessional team and organization to reflect a culture of caring and demonstrate a family centered approach.
- Processes and clinical guidelines must be developed and implemented to prevent or resolve conflict at the family level and between the health care team and family ensuring that decisions are made in the best interest of the patient.
- On-site debriefings or counseling must be available to support the critical care nurse and the interdisciplinary team.
This position statement on providing end-of-life care is based on certain ethical values and principles:
- Health care professionals ought to act in ways which promote and respect informed decision-making of the individual for whom they are providing care. This provision of care ensures the preservation of dignity and maximization of health benefits.
- Patients have a right to information about diagnosis, prognosis, and treatment options, including benefits and risks. Patients who are considered capable to make treatment decisions but are non-verbal due to ventilation or sedation require opportunities to be informed about their current health status through alternative methods of communication and sedation interruptions (when possible) to allow them to make treatment decisions including continuation of life support*.
- Patient/Family Centered Care is continuous and is especially important at end of life in order to support families faced with making decisions that would reflect the patient’s wishes when the patient is not able to do so.
- Discussions with the patient are essential to determine wishes about end of life care. If the patient lacks the capacity to make treatment decisions, discussions must then take place with the designated decision-maker(s) and/or family to ascertain if they are aware of the patient having any expressed end of life care wishes.
- Nurses work collaboratively with the interdisciplinary team to advocate for the implementation of the patient’s wishes ensuring that that the patient and family have information, knowledge and support to come to consensus about end of life decisions.
- When advanced care directives** are in place, every effort must be made to ensure that these directives are followed in order to respect the rights and wishes of the patient.
- The plan of care for each patient must be developed with respect to all aspects of individual’s diversity.
- * Life support refers to the provision of any or all of the following: assisted ventilation, inotropic/vasopressor support, and all or any mechanism utilized to maintain and/or support the life of a patient. The decision to provide cardiopulmonary resuscitation and life support should be supported by clear organizational guidelines.
- ** Advanced care directives may be defined as a formal written document outlining the wishes of the patient with regard to health care.
Approved by the CACCN Board of Directors
Date January 19, 2011
American Association of Critical Care Nurses. (2005). Acute and critical care choices guide to advance directives. Aliso Viejo, CA: Author.
Bach, V., Ploeg, J., Black, M. (2009). Nursing roles in end-of-life decision making in critical care settings. Western Journal of Nursing Research, 31(4), 496 – 512.
Browning, A. (2009). Empowering families in end of life decision making in the intensive care unit. Dimensions of Critical Care Nursing, 28(1), 18 – 23.
Canadian Nurses Association. (2008). CNA Position Statement: Providing nursing care at the end of life. Ottawa, ON: Author.
College of Nurses of Ontario. (2009). Guiding decisions about end of life care, 2009. Toronto, ON: Author.
Espinosa, L., Young, A, Walsh, T. (2008). Barriers to intensive care unit nurses providing terminal care. Critical Care Nursing Quarterly, 31(1), 83 – 93.
Hawryluck, L., Harvey, W., Lemieux-Charles, L. Singer, P. (2002). Consensus guidelines on analgesia and sedation in dying intensive care unit patients.
BMC Medical Ethics, 3(3). Retrieved from http://www.biomedicalcentral.com/1472-6939/3/3
Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care Bioethical Board (2006). End-of-life and the intensivist: SIAARTI recommendations on the management of the dying patient. Minerva Anesthesiologica, 72(12), 927-948.
Kuschner, W., Gruenewald, D., Clum, N., Beal, A., Ezeji-Okoye, S. (2009). Implementation of ICU palliative care guidelines and procedures. CHEST, 135, 26-32. Retrieved from www.chestjournal.org.
McMillen, R. (2008). End of life decisions: Nurses perceptions, feeling and experiences. Intensive and Critical Care Nursing, 24, 251-259.
Millner, P., Paskiewicz, S., Kautz, D. (2009). A comfortable place to say goodbye. Leadership Dimension, 28(1), 13-17.
Mosenthal, A., Murphy, P., Barker, L., Lavery, R., Retano, A., Livingston, D. (2008). Changing the culture around end-of-life care in the trauma intensive care unit. The Journal of Trauma Injury, Infection and Critical Care, 64, 1557-1593.
Reynolds, S., Cooper, A., McKneally, M. (2007). Withdrawing life-sustaining treatment: Ethical considerations. Surgical Clinics of North America, 87, 919-936.
Treece, P. Communication in the intensive care unit about end of life (2007). AACN Advanced Critical Care, 18(4), 406–414.
Treece, P., Engleberg, R., Shannon, S., Nielsen, E., Braungardt, T., Rubenfeld, G., Steinberg, K. & Curtis, J. (2006). Integrating palliative and critical care: Description of an intervention. Critical Care Medicine, 34, 380-386.
Truog, T., Campbell, M., Curtis, J. (2008). Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American Academy of Critical Care Medicine. Critical Care Medicine, 36(3), 953–961.