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Current Anaesthesia & Critical Care (2006) 17, 283–288

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FOCUS ON: GAT & CONTROVERSIES IN ANAESTHESIA

Palliative care on the intensive care unit

J.F. Cosgrovea,�, I.D. Nesbitta, C. Bartleyb

aFreeman Hospital, Newcastle upon Tyne, NE7 7DN, UKbQueen Elizabeth Hospital, Gateshead, NE9 6SX, UK

KEYWORDSAnalgesia;Doctrine of DoubleEffect;Education;Euthanasia;Palliation

ee front matter & 2006acc.2006.10.001

ng author. Tel.: +44 19131180.ess: joe.cosgrove@nuth

Summary When futility of ongoing active treatments has become apparent incritically ill patients, effective palliative care must be instituted. Such care includesrelief from the physical, emotional and spiritual aspects of dying. Five domains havebeen described; they are adequate pain and symptom relief, avoidance ofinappropriate prolongation of dying, achieving a sense of control, having burdensrelieved and strengthening relationships with loved ones. The mainstay of such careis frequently effective analgesia. Other physical provisions include sedation,temperature control, anti-emesis, reassurance (if conscious) and good basic caree.g. oral toilet, wound care, pressure area care, cleaning of soiled areas. Culturaland religious aspects must also be considered. Once analgesia and sedation areeffective any intervention not advancing patients’ goals (i.e. ‘to have a good death’)should be eliminated. Critical care staff should also provide for the patient’s familyand have an understanding of the legalities of death e.g. certification, coroner, etc.and medico-legal examples of conflict. Senior clinicians therefore have a pivotal rolein guiding an individual’s care, minimizing conflict and educating others in both thepracticalities of effective palliative care and the controversies surrounding thesubject e.g. Doctrine of Double Effect and Euthanasia.& 2006 Elsevier Ltd. All rights reserved.

Introduction

When futility has been recognized in the criticalcare setting, staff have a duty to provide effectivepalliative care and thereby relieve pain andsuffering arising from physical, social, emotionaland spiritual aspects of the patient’s environment.Those immediately involved are the patient andmedical/nursing staff under whose care the patient

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is being treated, but others include the patient’sfamily/loved ones, the extended clinical teami.e. (other staff on the intensive care unit and theadmitting team) and where appropriate religious,cultural or social representatives. This articleprimarily deals with immediate aspects of pallia-tive care and focuses on the patient and how theprovision of palliative care (in a critical caresetting) is influenced by ‘socio-geographic andbioethical/medico-legal aspects of UK society;the critical care team and the patient’s family (inthe immediate environment at the time of death)along with how these concerned parties interact.’

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The patient

In the critical care setting, many patients under-going palliative care have already lost conscious-ness. However, some patients remain conscious andmay have previously played a role in the decision-making surrounding their care e.g. refusing life-sustaining treatments through perceiving that suchinterventions would not be in their best interests.In such cases, patients must be reassured andprepared for the process of palliative care i.e.removal of life-sustaining therapies does not con-stitute ‘removal of care,’ distressing symptoms willbe treated appropriately and any specific culturalbeliefs will be met. Research from North Americahas cited five end-of-life domains as being ofimportance to a dying patient.1 They are:

�

adequate pain management and symptomaticrelief (in particular dyspnoea but also symptomssuch as nausea),2

�

avoidance of inappropriate prolongation of thedying process, � to achieve, where possible, a sense of control for

the patient,

� to have burdens relieved, � to strengthen relationships with loved ones.

If the patient has specific religious beliefs,consultation with local cultural/religious groups isoften invaluable and organizations such as theIntensive Care Society provide documentaryadvice on end-of-life care in such circumstances.3

Such aspects of care are discussed elsewhere in thisjournal.

In the diagnostic/curative model of intensivecare, criteria for interventions are gauged on theireffectiveness in improving physiological para-meters and a drive towards cure. In the palliativemodel, criteria relate to whether or not anintervention will afford appropriate relief fromsuffering and meet the end-of-life domains.1 Themainstay of this process is invariably effectiveanalgesia. Despite anaesthetists and intensive careclinicians being skilled in both assessing andmanaging pain, evidence exists to demonstratethat many patients (on intensive care and else-where) die with treatable pain through a combina-tion of bias towards ‘treating diseases rather thansymptoms’ and the relative subjectivity of painassessment.4 While pain scales are of value in acutepain assessment they are often best applied topostoperative pain management rather than to the‘semi-conscious dying patient’ on the intensivecare unit. Basic principles of pain assessment and

analgesic requirements in such instances relate tolevel of consciousness, respiratory patterns (ifbreathing spontaneously) and haemodynamics inresponse to stimuli. Appropriate analgesics aretherefore usually administered to attenuate theabove-related adverse signs and symptoms.5

Opiates are frequently used and in addition totheir analgesic effect contribute to the relief ofdistress and suffering through sedation and at-tenuation of adverse symptoms such as breath-lessness. In a palliative care setting, the use ofmorphine is commonplace, although within UKcritical care units many patients may have alreadybeen commenced on other intravenous opiateinfusions e.g. fentanyl as part of a sedative regi-men. Fentanyl is shorter acting than morphine,(potentially raising concerns about its long-termeffectiveness for palliation) but its half-life in-creases with prolonged administration e.g. as in theintensive care patient, reducing such concerns6 andmaking it preferable to other short-acting opiates,particularly when changing infusion syringes. Bothdrugs also reach peak effect within 5min ofadministration making them effective, rapidlyacting analgesics for palliative care.6

In conjunction with analgesia is the need torelieve ‘suffering’ and ‘distress.’ The distresscaused by breathlessness and nausea is often easyto assess and treat; however, other aspects ofassessing distress remain subjective. Many patientsin the hope of having burdens relieved wish to ‘diein their sleep.’ To this effect, sedatives such aspropofol and benzodiazepines (often already beingadministered) are useful pharmacological adjuncts.Benzodiazepines are also anxiolytic and may pre-vent the development of premorbid seizures.7 Itshould, however, be noted that suffering can have aprofound redemptive meaning for some patientsso that, if awareness of this exists, clinicians are ina position to move towards individualizing pallia-tive care.8

Pain, discomfort and suffering can be furtherrelieved through appropriate control of tempera-ture (pyrexia and hypothermia), effective anti-emesis, reassurance (if conscious) and good basicpersonal care including oral toilet, physiotherapy,wound care, pressure area care and cleaning ofsoiled areas. Hunger and thirst have been cited asproblematic areas in both the humanitarian andlegal aspects of end-of-life care. Administeringfood and fluid can be regarded as a basic expressionof humanity. However, the importance and effec-tiveness of the symbolism is uncertain; hunger andthirst are physiological responses to dying andassociated dehydration and electrolyte distur-bances may actually contribute to sedation rather

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than cause distress e.g. uraemia from dehydrationcan be sedative and a so-called ‘starvation euphor-ia’ can arise from endogenous opioid productionand the analgesic effects of ketosis.9 Artificialnutrition (while symbolic and cited as a require-ment by Burke10) may prolong the dying processand cause discomfort through gastric distension,etc.11,12 Additionally, while artificial hydration(particularly intravenous) could alleviate any dis-comfort from dry mucous membranes it has to bebalanced against discomfort and distress caused byworsening of peripheral oedema, ascites, pleuraleffusions, etc.13

Once effective and appropriate levels of analge-sia and sedation are achieved, any interventionthat does not advance the patient’s goals (i.e. a‘good death’) should be eliminated. This generallyrelates to levels of organ support specific to anintensive care unit and can appear unambiguous;however, diversity in approach exists relating moreto physicians rather than the specifics of anindividual case.14,15 Such processes are influencedby doctors’ cultural and religious beliefs and anuncertainty over diagnosis even in the face ofoverwhelming multi-organ dysfunction and futility.Other reasons include a reluctance to stop un-familiar therapies e.g. a renal physician may becomfortable with the decision to cease renalreplacement therapy but not with a decision tostop inotropic or ventilatory support.16 Here thereis clearly a leadership role for the intensive carephysician who, regardless of base speciality, has abroad working knowledge of the majority of formsof organ support and should therefore be in aposition to minimize ambiguities. Such decisionmaking appears to work well with respect towithdrawal of active therapies such as inotropes,renal replacement and positive end expiratorypressure (PEEP); however, uncertainty continuesto exist with respect to management of the airwayi.e. the appropriateness of extubation or decannu-lation of a tracheostomy.17,18 Clearly such actionsare inappropriate if the patient is pharmacologi-cally paralysed or has a tracheostomy and knownairway obstruction above the level of the tra-cheostomy i.e. death could be potentially precipi-tated by asphyxiation rather than disease andparalysis will make assessment of pain and con-sciousness difficult. Nevertheless, extubation ver-sus ‘palliative wean’ in other circumstanceswarrants further discussion.

With respect to palliative weaning the mainadvantage is avoidance of significant upper airwayobstruction with potential distress and discomfortfrom stridor and secretion retention. It may alsoreduce anxiety in the family and critical care team.

Although this is a secondary issue it remainssomething that has to be considered.17 It shouldbe stated, however, that it has the potential to beconfused with an attempt at cure if communica-tions are unclear. In contrast, extubation does notprolong the dying process and allows the patient tobe free from an ‘unnatural’ endotracheal tube andcan therefore carry a greater moral transparency.19

Problems relating to discomfort and distress duringextubation can be minimized by appropriatelytimed administration of sedation, analgesia andrespiratory toilet.

An extra issue to be considered in the provision ofpalliative care is discharging the patient home or tohospice care. This action can provide a sense ofcontrol for the patient, relieve burdens and permitstrengthening of relationships with loved ones.Recent evidence relating to such managementcomes from New Zealand where the process hasallowed for an improved quality of care for thepatient and a more positive experience for thefamily with an associated sense of closure.20,21

From this, and our personal experience, dischargehome can be achieved in selected cases (particu-larly with patients capable of breathing sponta-neously) if clear planning occurs. Such planningrequires liaison with hospital and communitypalliative care teams, general practitioners andthe local ambulance service. Factors to considerinclude analgesia, tracheal and oropharyngealsuctioning, locality of and access to the patient’shome, the potential for the coroner’s involvementand advice to general practitioners in relation todeath certification.20

Euthanasia and the Doctrine of DoubleEffect

Regardless of the stage of management, effectivecommunication is vital for good practice in end-of-life care. Failure to provide appropriate channelsfor discussion can cause confusion, uncertainty andeven conflict where concerned parties can poten-tially mistake withdrawal of life-prolonging treat-ments in the dying patient as euthanasia.Therefore, while it is not the purpose of the articleto debate the legalities of euthanasia, the legal andbioethical distinction between euthanasia and theDoctrine of Double Effect warrants discussion priorto outlining the needs of families and the role of acritical care team in palliative care.

Euthanasia is defined as ‘Intentional killing by actor omission of a dependent human being for theiralleged benefit.’ It remains illegal under UK law.21

The key word is ‘intentional.’ If death is not

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intended by an act or an omission it is noteuthanasia. Intent is also the core principle of theDoctrine of Double Effect in that there is adistinction between foreseeing and intending; theconsequences of an action (cessation of activetreatments) by a doctor may be known to bringabout a ‘bad’ result (death of a patient); however,if the ‘bad’ result of the action is not part of thedoctor’s intention, the action is not forbidden22,23

e.g. the intention of administrating an intravenousopiate is to provide effective analgesia (with theknown potential side-effect of a respiratory ar-rest). The intent is not to precipitate a respiratoryarrest and thereby ‘provide effective analgesia.’

It has been argued that the Doctrine of DoubleEffect requires a purity of intention that may not inreality exist.24 It is in effect a ‘moral loophole’absolving physicians of their responsibilities. How-ever, with evidence to demonstrate that doctorsoften under-treat pain and suffering,4 the Doctrineof Double Effect has the potential to act as achannel for effective palliative care preventingsub-optimal treatment in dying patients.

The role of the critical care team

The entire critical care team has a role in providingeffective palliative care. At the bedside, this isprimarily the medical and nursing staff caring forthe patient, but can extend to all staff on theintensive care unit that have direct contact withthe patient and family members. This includes theadmitting team, physiotherapist, appointed carers,religious or cultural representatives, clerks andsecretaries. The basic roles (as discussed) aremaintaining dignity and providing symptom controlbut are often extended to encompass communica-tion, diminishing any ‘moral burden’ that thefamily may experience and providing relativeswith, or directing them to options such as bereave-ment counselling, religious help, etc.25

Members of the team also have to provideguidance on the legal aspects of death includingcertification, post-mortems, the coroner and whereappropriate organ donation. Clarity and empathyare therefore necessary and in such circumstancesit is imperative that senior clinicians assume aprominent leadership role as they are often in aposition to emphasize that excellent care at theend of life is the priority for all concerned, therebyalleviating concerns.

The skills exercised in these situations of ‘break-ing bad news’ are inherent to some and allied to‘common sense.’ Even if such skills are notimmediately inherent, appropriate methods can

be developed to improve communication andminimize conflict if certain principles are adheredto.25–27 These include:

�

avoiding firm predictions in the first instance ofan admission to intensive care and not givingfalse hope, � wherever possible delivering bad news in person, � demonstrating empathy, compassion and main-

taining eye contact,

� showing compassion where appropriate, � avoid well-intended cliches such as ‘she’s at

peace now.’ These can be perceived as offen-sive,25

�

documentation of what was said, recordingexactly who was present.

There is also a requirement for the team todebrief at both informal and formal levels. In ourexperience, many experienced staff (medical andnursing) have learnt to cope with end-of-lifesituations and can often informally debrief eachother without the immediate functioning of anintensive care unit being affected. This abilitycould be something to channel into the training ofothers in the provision of effective palliative care,the communication of end-of-life decisions and thesocial, emotional and administrative aftermath.28

Support of the family

Although the needs of the patient are paramount tothose providing care, there is a growing consensusthat family and others close to the patient mustalso be provided for.25 Such support is intertwinedwith the role and needs of the critical care team(above) and the communications involved (betweenstaff and relatives) may be difficult due to both anabsence of a prior relationship and the nature ofthe relationship they suddenly find themselvesinvolved in.25,29,30 Thus, in addition to the afore-mentioned need for empathy and clarity, staff mustbe aware of the general needs of family and lovedones faced with a dying relative/friend on anintensive care unit.25 These needs are:

�

a wish to be helpful, � to be kept informed of the patient’s changing

condition and to comprehend the process thathas lead to death,

� a desire for assurance and comfort, � a need to express emotions, � a need to find meaning in the dying process, � basic hydration, food and rest,

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Palliative care on the intensive care unit 287

�

the need to resolve conflicts between family andhospital staff over the care given to the patient inthe (sometimes long distant) past. In such situa-tions, it may be necessary to formally agree to setaside such debates and discussion until either thepatient has died, or the acute episode hasresolved. At such junctures the family should alsobe provided with information about how to pursuecomplaints, get further information from cliniciansetc. It is essential to avoid a total breakdown incommunications between staff and family, regard-less of previous unpleasant encounters.

In addition to managing conflict over genuineproblems, staff may bear the ‘irrational’ bruntof relatives’ distress with grieving emotionsbeing directly transferred toward them.31 Emotionsinclude:

�

inability to concentrate/make decisions, � inability to absorb information and/or use it

effectively,

� panic, � demanding/irrational behaviour, � aggressive/abusive behaviour, both verbal and

physical,

� withdrawal/passivity.

To inexperienced members of staff such reactionscan appear disproportionate and aggressive. Seniorstaff must therefore be able to understand suchreactions and guide junior colleagues through theprocess of dealing with them.

Other issues of concern to the relatives andfriends of a dying person include contacting distantfamily members and the effect of possible inter-necine conflict on family relationships. Personalexperience and communications suggest that thelatter can be difficult to resolve aside from‘keeping peace’ within the hospital; however, theformer, in the current technological climate isoften straightforward. And so in many circum-stances, prolonging life to allow a patient’s ‘affairsto be put in order’ by a relative (from overseas)visiting the bedside may be appropriate32; however,when faced with such circumstances the staff must(with reference to the futility debate) treat eachcase on its merits and base their care on appro-priate bioethical and legal guidelines.33,34

Summary and conclusions

The provision of palliative care is a necessary partof an intensive care clinician’s work. Understanding

the concepts of futility and patients’ needs at theend-of-life are essential, and include an under-standing that, although treatments may be re-moved, care must continue to be provided.35

Appropriateness of the care provided is enhancedby understanding the needs of patients, theirrelatives and the clinical team. Communicatingdecisions in an empathic and unambiguous mannerenhance a process that can be further aided bysenior clinicians assuming leadership roles in termsof both the management of individual cases and theorganization of staff and systems to provideeffective, multi-disciplinary treatment in a reflec-tive environment.36,37 Adapting palliative caremodels from other medical specialties that havealtered the culture of end-of-life care througheducation and evaluation is likely to have asignificant role in such a process.38

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