Death is an everyday occurrence in the critical care unit. The dying frequently do so in critical care units. For many, life-support interventions have not helped to mitigate their suffering, but have rather added the agony and burden of a prolonged dying process. Death, which we all wish to be peaceful and to occur in the presence of loved ones, has become artificial, away from the family surrounded by the paraphernalia of modern critical care. Prolonged and futile life support has undoubtedly imposed enormous economic strain on patients and families. Potentially salvageable patients can be denied ICU care when scarce beds and resources are consumed in a futile search of cure where death appears inevitable. Setting goals appropriate to clinical situations of poor prognosis are an integral part of critical care. Quality critical care requires that the practice be well grounded in ethical principles and that the ICU staff are trained in the skills of end of life care. A consensus regarding the practices relating to EOL care in Indian ICUs should eventually lead to the evolution of appropriate legislation in keeping with the changing needs of critical care practice.

Position Statement of the Indian Society of Critical Care Medicine

Mani RK, Amin P, Chawla R, Divatia JV, Kapadia F, Khilnani P, Myatra SN, Prayag S, Rajagopalan R, Todi SK, Uttam R, Balakrishnan S, Dalmia A, Kuthiala A. Limiting life-prolonging interventions and providing palliative care towards the end-of-life in Indian intensive care units. Indian J Crit Care Med 2005;9:96-107

Checklist for initiating EOL discussions

1. Advanced age coupled with a poor premorbid state due to chronic debilitating diseases, e.g., advanced chronic obstructive pulmonary disease (COPD) requiring home oxygen and/or bilevel pressure support or with severe impairment of quality of life; advanced interstitial lung disease on oxygen therapy with failed medical treatment, chronic renal failure requiring long-term dialysis, chronic liver disease, advanced congestive heart failure.
2. Catastrophic illnesses with organ dysfunctions unresponsive to a reasonable period of aggressive treatment.
3. Prolonged coma (in the absence of brain death) due to acute nonreversible causes or chronic vegetative state.
4. Incurable chronic severe neurological states rendering meaningful life unlikely, e.g., progressive dementia, quadriplegia with ventilator dependency.
5. Progressive metastatic cancer where treatment has failed or patient refuses treatment.
6. Post cardio-respiratory arrest, nonrestoration of comprehension after a few days.
7. Comparable clinical situations coupled with a physician prediction of low probability of survival.
8. Patient/family preference to limit life support or refusal to accept life support.

Recommendations
1. The physician has a duty to disclose to the capable patient or family, the patient’s poor prognosis with honesty and clarity when further aggressive support appears nonbeneficial. The physician should initiate discussions on the treatment options available including the option of no specific treatment.

2. When the fully informed capable patient or family desires to consider palliative care, the physician should offer the available modalities of limiting life-prolonging interventions. The patient or family should be clearly made aware of the available options for the use of life-sustaining supports as follows:

3. The physician must discuss the implications of forgoing aggressive interventions through formal conferences with the capable patient or family, and work towards a shared decision-making process. Thus, he accepts patient’s autonomy in making an informed choice of therapy, while fulfilling his/her obligation to provide beneficent care.

4. Pending consensus decisions or in the event of conflicts between the physician’s recommendations and the family’s wishes, all existing supportive interventions should continue. The physician however, is not morally obliged to institute new therapies against his/her better clinical judgment.

5. The discussions leading up to the decision to withhold life-sustaining therapies should be clearly documented in the case records, to ensure transparency and to avoid future misunderstandings. Such documentation should mention the persons who participated in the decision-making process and the treatments withheld or withdrawn.

6. The overall responsibility for the decision rests with the attending physician/intensivist of the patient, who must ensure that all members of the caregiver team including the medical and nursing staff agree with and follow the same approach to the care of the patient.

7. If the capable patient or family consistently desires that life support be withdrawn, in situations in which the physician considers aggressive treatment nonbeneficial, the treating team is ethically bound to consider withdrawal within the limits of existing laws.

8. In the event of withdrawal or withholding of support, it is the physician’s obligation to provide compassionate and effective palliative care to the patient as well as attend to the emotional needs of the family.

ABSTRACT

46. Limitation and withdrawal of intensive therapy at the end of life: practices in intensive care units in Mumbai, India. Kapadia F, Singh M, Divatia J, et al. Crit Care Med. 2005 Jun;33(6):1272-5.

Objective : To describe the practices in intensive care units in Mumbai hospitals regarding limitation and withdrawal of care at the end of life. Design: Review of prospectively collected data. Settings : Intensive care units of four major hospitals (two private tertiary referral general hospitals, one mixed public and private cancer referral hospital, and one large public hospital). Patients : Hospital and intensive care unit patients who died during the study period. Intervention : None. Measurements and main results : We measured the percentage of hospital deaths occurring inside and outside intensive care units and the incidence of withholding intubation, withholding other therapy, and withdrawing therapy for deaths in the intensive care unit. The proportion of hospital deaths that occurred in an intensive care unit was 14% in the cancer hospital, 23% in the public hospital, and 58-73% in the two private hospitals (chi-square test for trends, p < .0001). Of the 143 deaths that occurred in intensive care unit, limitation of care occurred in 49 patients. Twenty-five percent of these patients were not intubated terminally, 67% were initially intubated and ventilated but failed to recover and subsequently had no further escalation of therapy, and 8% had withdrawal of therapy. Therapy was limited in 19% of deaths in the public hospital intensive care unit (odds ratio, 0.44; 95% confidence interval, 0.2-0.97) vs. 40%, 41%, and 50% of deaths in the other three intensive care units. Conclusions: Therapy is limited in a significant proportion of intensive care unit patients. Significant differences in the practice of limitation of therapy exist between public and private hospitals. Lack of access to a limited number of intensive care unit beds, especially in the public hospital, may constitute implicit limitation of care.