In the intensive care unit (ICU), we work hard to help patients overcome the most critical phase of illness. We titrate vasoactive drugs and administer fluids to obtain hemodynamic stability, insert balloon pumps or ventricular assist devices to help maintain adequate circulation, mechanically ventilate patients with acute respiratory distress syndrome, and initiate dialysis or continuous arteriovenous hemofiltration for those with kidney failure. We go to great lengths to give our patients every chance at survival, but sometimes, it’s not enough, and we need to know when to let them rest. As a critical care nurse, I’ve taken care of individuals who were experiencing an acute life-threatening illness or an exacerbation of a chronic disease leading to ICU admission. I’ve witnessed many patients lose their battle, and in those intimate moments, I held their hands, wiped away endless tears, and hugged those left behind. It’s never easy, but end-of-life care is an invaluable part of the job.
End-of-Life Care
In general, palliative care involves preventing and relieving suffering for any patient with a serious illness. End-of-life care is a subset of palliative care that occurs when the patient can no longer be sustained on life support (Isaac, 2024). Patients enter a phase when their life expectancy may be limited to hours, days, or weeks. Once the family has accepted the prognosis, they must consent to withdraw care or agree not to add further interventions or life-prolonging measures. Our focus shifts from cure to comfort, maintaining the patient’s dignity and meeting their spiritual needs. A “comfort measures only” care plan is initiated and involves symptom alleviation, pain management, and minimizing invasive and uncomfortable procedures. The goal is to provide patients, their families, and caregivers with the best possible quality of life during this challenging time.
Palliative care is indicated when patients meet any of the following criteria (Isaac, 2024):
- Chronic critical illness, typically an ICU stay greater than 5 to 14 days
- Use of medical procedures in patients with life-limiting illness (e.g., tracheostomy, percutaneous gastrostomy tube, or extracorporeal life support)
- Age 80 years or over
- Significant medical morbidities or reduced baseline functional status
- History of chronic or incurable life-limiting illnesses (e.g., metastatic cancer, advanced respiratory, cardiac, or kidney disease; amyotrophic lateral sclerosis)
- Specific acute illnesses (e.g., anoxic brain injury following cardiac arrest, intracerebral hemorrhage requiring mechanical ventilation)
- Overall poor prognosis as determined by a healthcare provider
The primary pillars of palliative care include (Isaac, 2024):
- Assessing and managing symptoms
- Aligning the patient’s goals of care with their values and preferences
- Communicating continually and consistently with the patient and all members of the care team
- Providing psychosocial, spiritual, and practical support to the patient and their caregivers
- Coordinating across all points of care
Communication
Communication is the cornerstone of end-of-life care. Advanced directives, or living wills, help document the patient’s values and wishes. However, these documents do not always address all treatment choices. If an advanced directive has not been completed, nurses and the entire healthcare team should be able to accurately assess the patient’s ability to make informed decisions, known as ‘decisional capacity.’ This assessment can be complex and time-consuming but is of utmost importance, particularly before the patient is intubated, sedated, or develops a change in mental status, such as delirium. Talk to patients early and openly when admitted to the ICU about their values and goals regarding end-of-life care. Include family, caregivers, and surrogates in the conversation when possible and with patient approval.
Decisional capacity is different from decisional competence. Decisional capacity is a clinical term that refers to a patient’s ability to make decisions and applies to a specific decision. Decisional competence is a legal term that requires judicial determination and applies to all decisions (Isaac, 2024). To evaluate decisional capacity, the patient should be able to write, use a word board, or another communication tool to convey their wishes. When determining decisional capacity, the CURVES mnemonic may be helpful (Isaac, 2024):
- C: Assess if the patient can choose and communicate a choice.
- U: Determine if the patient understands the decisions, the potential risks, benefits, alternatives, and consequences.
- R: Ask the patient to provide a reason for the decision made. Is the reason coherent and rational?
- V: is the decision consistent with the patient’s values?
- E: If the above criteria are not met, assess whether the situation is a true emergency.
- S: Is there a legal surrogate decision-maker?
Withdrawal of Life Support (Isaac, 2024)
When the decision has been made to withdraw life-sustaining treatments, maximize patient comfort, and limit unnecessary interventions.
- Explain to the family and caregivers what to expect during the dying process.
- Avoid phrases such as withdrawal of care and agonal respirations. Use terms such as “withdrawal of life-sustaining treatments” and “expected and irregular breathing patterns.”
- Only continue treatments that support patient comfort.
- Provide a quiet and private space for patients, families, surrogates, and caregivers.
- Silence alarms.
- Transfer patients only when necessary to ensure continuity of care.
- Avoid the use of neuromuscular blocking agents as these make the patient appear comfortable but do not relieve pain or provide sedation.
Spirituality
Finally, but most importantly, respectfully address the spiritual needs of your patients, their families, and caregivers, which has been shown to improve the quality of life in their remaining days. Utilize the resources available at your institution, such as spiritual care service providers and hospital-employed chaplains and pastors, as it can be challenging to manage both your patient’s physical and emotional health.
Saying Goodbye
It was never easy saying goodbye to a patient, whether I cared for them for one shift or over several weeks. But I always did my best to honor each of them in those last moments, ensuring they were never alone and that they passed away with dignity. Remember, your work as a nurse is important - never forget it!
.png.aspx "LWW-Blog-Article-CTA-(1).png")
Tags :