'End of Life Care in the Intensive Care Unit (ICU)' (Presentation from Acute Hospital Network, March 2015) [AHN34]

1. TedTalk
http://ed.ted.com/on/5AD389V3#review
Dr Rob Fowler, Critical Care & General Medicine
Physician at Sunnybrook Hospital in Canada.
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2. 15/06/2015 1
End-of-Life Care
in the Intensive Care Unit
Denis Casey
End-of-Life Care Coordinator
University of Limerick Hospital Group
denis.casey@hse.ie 087-6544070

3. The Intensive Care Unit
The Intensive care unit (ICU) caters for patients with
severe and life threatening illnesses and injuries, which
require constant, close monitoring and support from
specialist equipment and medications in order to
support and ensure normal bodily functions.
Typically have higher staff-to-patient ratio, usually 1:1
Nurse patient ratio.

5. Nature of the ICU
• Highly technological care
• Curative focus – primary goals are to help patients
survive acute threats to their lives while preserving and
restoring quality of life
• 60- 70% of ICU patients are not capable of making
decisions due to illness/sedation
• 1-2% of all hospital beds
• Costs €1,500- €3,000 per day depending on therapies

6. 68%
20%
12%
Wards
ICU
A&E
Place of Death – in Irish Hospitals
68%
20%
12%
Wards
ICU
A&E
National Audit of End of Life Care (2010). Audit of 1,000 patients deaths (18+)

7. Deaths in ICU – international research
• Approx 20% of all hospital deaths occur in ICU
(ICNARC 1999-2006, Billings et al 2006, Morgan 2008)
• 42% of patients who die in hospital have spent part of
their last 3 days of life in a specialist unit
(Cybulski 2011, Canada )
• Death can be sudden/ unexpected
• 70 - 90% of patients who die in ICU do so after a
decision to limit or withdraw therapy
(Truog 2001; USA, Carlet et al 2004; France)

8. Paediatric deaths in ICU
• 20% of all adults who die in hospital will die in an ICU.
Most patients die in ward settings.
• In children’s hospitals, it’s the opposite.
• Case study: Our Lady’s Children’s Hospital, Crumlin
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9. Paediatric deaths in ICU (Crumlin Hospital)
PICU
86%
Cardiac
7%
Wards
6%
HaemOncology
1%
2010 2011 2012 2013 2014
Total
2010-2014 % Deaths
PICU 51 54 52 45 64 266 85.8%
Cardiac 3 5 2 3 10 23 7.4%
Wards 7 2 4 2 2 17 5.5%
HaemOncology 1 1 1 1 0 4 1.3%
Total 62 62 59 51 76 310 100.0%

10. Limitation of Treatment
Where a treatment which might be beneficial is
continued to a predetermined upper limit, dose or time
period.
e.g. Limit of vasopressors, period of CVVH (Dialysis)
(CCaNNI 2009)

11. Withholding Treatment
A treatment which might be beneficial in a different
scenario or patient is not initiated. e.g. A decision is
made not to re-intubate a patient or not initiating CVVH
(CCaNNI 2009)

12. Withdrawal of treatment
A treatment which might be beneficial in a different
scenario or patient is reduced and stopped.
e.g. Inotropes, DNaCPR
(CCaNNI 2009 )

13. Decisions to withhold or withdraw life
support
53%
47% Intensive Care Unit
Other areas
4,248 ICU deaths in 17 European countries

14. Mater Hospital. ETHICUS study
1999/2000 – 70% of patients who died in ICU had a
decision made to withhold or withdraw life-sustaining
therapy but only 72% of decisions were documented.
(Collins, Phelan, Marsh & Spring 2006)

15. Withdrawal of care
Dialysis
↓
Diagnostic tests
↓
Vasopressors
↓
IV Fluids
↓
Monitoring
↓
Artificial feeding
↓
Ventilation
(Faber-langendoen 2000)

16. Challenges in End-of-life care in ICU?
Curative Vs Comfort

17. Discussion
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18. References
• Billings, J. A., Keeley, A., Baunam, J., Cist, A., Coakley, E., Dahlin, C., et al. (2006). Merging
Cultures:Palliative care specialists in the medical intensive care unit. Critical Care Medicine ,
s388-s393.
• Cartlet, J., Thijs, L. G., Antonelli, M., Cassell, J., Cox, P., Hill, N., et al. (2004). Challenges in end-
of-life care in the ICU - statement of the 5th International Consensus conference in Criticcal care:
Brussels, Belgium, April 2003. Intensive Care Medicine , 30, 770-784.
• Collins, N., Phelan, D., Marsh, B., & Sprung, C. (2006). End of life care in the intensive care
unit:the Irish Ethicus Data. Critical Care and resuscitation , 8 (4), 315-320.
• Critical Care Network of Northern Ireland. (2009). End-of-life care fro all Critical Care Patients.
Belfast: Northern Health and Social Care Trust.
• Cybulski, P. (2011). A critical care nurse's role in the provision of end-of-life care. Dynamics-
Canadian Association of Critical Care Nurses , 22 (4), 7-8.
• Faber-Langendoen, K., & Lanken, P. N. (2000). Dying Patients in the Intensive Care unit: Forgoing
Treatment, Maintaining Care. Annals of Internal Medicine , 133 (11).
• Morgan, J. (2008). End-of-life care in UK critical care units - a literature review. Nursing in Critical
Care , 13 (3), 152-161.
• Sprung, C., Cohen, S., & Sjokvist, P. (2003). End-of-life practices in European intensive care
units. the Ethicus study. JAMA , 290, 790-797.
• Truog, R. D., Cist, A. F., Brackett, S. E., Burns, J. P., Curley, M. A., Danis, M., et al. (2001).
Recommendations for end-of-life care in the Intensive care unit: The Ethics Committee of the
society of Critical care Medicine. Critical Care Medicine , 29 (12), 2332-2348.
• Irish Hospice Foundation (2010). National Audit of End-of-Life Care in Hospitals in Ireland.