Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine

improve the care of intensive care unit (ICU) patients during the
dying process. The recommendations build on those published in
2003 and highlight recent developments in the field from a U.S.
perspective. They do not use an evidence grading system because
most of the recommendations are based on ethical and legal
principles that are not derived from empirically based evidence.
Principal Findings: Family-centered care, which emphasizes
the importance of the social structure within which patients are
embedded, has emerged as a comprehensive ideal for managing
end-of-life care in the ICU. ICU clinicians should be competent in
all aspects of this care, including the practical and ethical aspects
of withdrawing different modalities of life-sustaining treatment
and the use of sedatives, analgesics, and nonpharmacologic
approaches to easing the suffering of the dying process. Several
key ethical concepts play a foundational role in guiding end-oflife
care, including the distinctions between withholding and
withdrawing treatments, between actions of killing and allowing
to die, and between consequences that are intended vs. those that
are merely foreseen (the doctrine of double effect). Improved
communication with the family has been shown to improve patient
care and family outcomes. Other knowledge unique to endof-
life care includes principles for notifying families of a patient’s
death and compassionate approaches to discussing options for
organ donation. End-of-life care continues even after the death of
the patient, and ICUs should consider developing comprehensive
bereavement programs to support both families and the needs of
the clinical staff. Finally, a comprehensive agenda for improving
end-of-life care in the ICU has been developed to guide research,
quality improvement efforts, and educational curricula.
Conclusions: End-of-life care is emerging as a comprehensive
area of expertise in the ICU and demands the same high level of
knowledge and competence as all other areas of ICU practice.
(Crit Care Med 2008; 36:953–963)
KEY WORDS: ethics; intensive care unit; end-of-life; palliative
care; decision making; quality improvement

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