1. Chapter Ten End-of-Life Issues Chapter 10-1 Fourth Edition Linda D. Urden Kathleen M. Stacy Mary E. Lough Priorities in C RITICAL C ARE N URSING Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

2. Slide 2 Objectives  Describe the impact of advance directives and advance care planning on provision of end-of-life care in the ICU.  Discuss the concepts of patient- and family-centered decision making.  Explain the need for symptom assessment and management during end-of-life care in ICU.  Discuss the role of collaborative practice on end-of-life care in the ICU.

3. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3 Recommendations to Improve End- of-Life Care  Patients with fatal illnesses and their family should receive reliable, skillful, and supportive care.  Health professionals should improve care for the dying.  Policymakers and consumers should work with health professionals to improve quality and financing of care. (Continued)

4. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4 Advance Directives  Also known as a living will or health care power of attorney  Encouraged to ensure patients receive the care they desired  Issues  Underused  Desires not discussed with primary physicians  Applicability

5. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5 Recommendations to Improve End- of-Life Care (Continued)  Health profession education should include end-of-life content.  Palliative care should be developed, possibly as a medical specialty.  Research on end of life should be funded.  The public should communicate more about the experience of dying and options available.

6. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6 Advance Care Planning  Communication of patient’s wishes between primary care providers and intensivists is critical.  Patient desires:  Aggressive care.  No aggressive care.

7. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7 Ethical/Legal Issues  Patient is respected as autonomous and able to make decisions.  If patient is unable to make decisions, respect should be accorded to surrogates.  Patient Self-Determination Act  Basic ethical principles  Beneficence  Nonmaleficence

8. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8 Comfort Care  Decision to withdraw life-sustaining treatments  Withdrawing and withholding are morally and legally equivalent  Families experience more stress in withdrawing  Goal of withdrawal is to remove treatments that are not beneficial and may be uncomfortable

9. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9 Do Not Resuscitate (DNR)  Should prevent initiation of CPR  Does not equate to “Do Not Care”  DNR should be written before withdrawal of life support

10. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10 Cardiopulmonary Resuscitation (CPR)  Decisions related to CPR are frequently delayed  CPR often offered as an option despite:  Low possibility of survival following CPR  Pain and suffering involved during and after CPR  Potential for decline in functional status following CPR

11. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11 Prognostic Tools  Acute Physiology and Chronic Health Evaluation (APACHE)  Multiple Organ Dysfunction Scores (MODS)

12. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12 Communication  Patient  Limited by illness severity  Family  Need support for decisions

13. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13 Withdrawal or Withholding Treatment Discussions about potential for impending death are never held early enough.  Proactive approach  Disagreement and distress for caregivers  Barriers to dying  Steps toward comfort care

14. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14 Palliative Care Patients near the end of life require aggressive care for their symptom management.  Pain management  Symptom management

15. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15 Withdrawal of Mechanical Ventilation  Time to initiate withdrawal should be established  Patient moved to a separate room  Notify noninvolved staff  Avoid loud conversation and laughter (Continued)

16. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16 Withdrawal of Mechanical Ventilation (Continued)  Pacemakers or implantable cardioverter- defibrillators should be turned off  Neuromuscular blockade discontinued  Removal of monitors—based on family responses (Continued)

17. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17 Withdrawal of Mechanical Ventilation (Continued)  Opioids and sedatives  Prevent dyspnea and anxiety  Ventilator settings  Reduced after patient comfort achieved  Alarms should be turned off  Terminal wean vs. extubation

18. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18 Organ Donation  Social Security Act Section 1138  The Joint Commission standards  Organ versus tissue donation  Determination of brain death

19. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19 Family Care Family means whatever the patient states is family  Communication needs  Waiting for “good news”  Family meetings  Family presence during CPR  Visiting hours (Continued)

20. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20 Family Care (Continued)  Family presence during CPR  Couple with staff support  Visiting hours  Following death

21. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21 Collaborative Care  End-of-life care domains  Patient- and family-centered decision making  Communication  Continuity of care  Emotional and practical support  Symptom management and comfort care  Spiritual support  Emotional and organizational support for ICU clinicians