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Caring for patients at the end of life in intensive care units
  1. Victoria Kendall, Clinical Skills Tutor
  1. Victoria Kendall is Clinical Skills Tutor, Undergraduate Centre, Manchester Royal Infirmary. At the time of writing she was Sister, Intensive Care Unit, Manchester Royal Infirmary. Email: Victoria.Kendall{at}CMMC.nhs.uk

Abstract

Intensive care units (ICUs) have developed over the last 40 years. Patients cared for in intensive care are now sicker than previously. Not all survive. Nationally, average mortality rates in ICUs can be 20–30%. In the technical ICU environment, staff members require education and training in end-of-life care decision-making, recognition of dying and patient/family care. Literature suggests that ICU patients whose management has shifted from curative to palliative, experience inconsistent quality of care. Furthermore, when intervention and cure are seen as the ‘norms’, systematic change in practitioners’ attitude and behaviour is required at the end of life. Central funding is available to support the NHS End of Life Care Programme, which aims to promote high-quality end-of-life care for all patients, regardless of diagnosis. This article examines ICU decision-making in relation to end-of-life care and ICU nurses’ experiences of caring for dying patients. It proposes the use of an integrated care pathway for patients dying in critical care environments. Conflicts of interest: none

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End-of-life care (EoLC) has received more emphasis in recent years throughout the healthcare system. The introduction of the NHS End of Life Care Strategy means healthcare trusts must now prioritise care of dying patients. The NHS End of Life Care Programme (http://www.endoflifecare.nhs.uk/eolc) supports the implementation of three key tools, one of which is the Liverpool Care Pathway for the Dying Patient (LCP). This care pathway incorporates the best elements of hospice care into one, easy-to-use tool. It facilitates effective communication with patients and families combined with symptom control (Ellershaw and Wilkinson, 2003). Recognition of dying is acknowledged as a challenge facing all healthcare professionals. It can be difficult to predict when death will occur (Maltoni et al, 2005). The issue of dying is even more complex in critical care environments because patients’ physical, psychological and clinical signs of dying are suppressed by sedation, ventilation and other interventions.

It is recognised that EoLC fails in the intensive care unit (ICU) environment due to lack of training, a focus on cure, disempowerment of nurses and the paternalism of ICU practitioners (Hodde et al, 2004). Intensive care was originally conceived to treat illness vigorously. Therefore, the notion that ICU practitioners should be equally skilled in curative interventions and EoLC appears contradictory (Ahrens et al, 2003). However, mortality rates of ICU patients can be 20–30% (Intensive Care National Audit and Research Centre, 2007), suggesting that critical care staff need levels of expertise in EoLC, similar to those of a hospice team.

Ninety per cent of complaints about health care in general concern poor communication. Between 30 and 40% of these do not proceed to litigation if families receive adequate explanation and an apology. Insensitivity of medical staff is often cited as a significant factor in complaints while ‘poor communication and insufficient information’ was the basis of 16% of complaints dealt with by the Healthcare Commission in 2007.

A review of literature reveals ICU-based EoLC as inconsistent and fraught with communication problems. Major problems exist related to recognising and agreeing that a patient is dying. A paucity of communication and collaboration between the various disciplines responsible for delivery and planning of ICU patient care means that ICU patients often receive invasive tests just before they die, at a time when they should be made comfortable (Rady and Johnson, 2004). Furthermore, ambiguity among clinicians regarding what is the most appropriate plan of care for patients (such as continuing aggressive treatment or commencing palliative care) may inhibit vital, timely communication with families. This inhibition of communication prevents families adjusting to and preparing for death, which can adversely affect their grieving process (Tuttas, 2002). According to the Marie Curie Palliative Care Institute Liverpool (2007), care of the dying is an indicator of the care provided for all sick and vulnerable patients. Care of the dying is urgent care, containing one opportunity to get it right and create a positive, lasting memory for relatives and carers.

The aim of this article is to examine three key areas in relation to EoLC in ICUs: decision-making surrounding EoLC in ICUs; ICU nurses’ experiences of caring for dying patients; and the implementation of an EoLC pathway in ICUs.

End-of-life decision-making in ICUs

Admission to an ICU is a major event in a patient’s (and family’s) life. Despite all of the treatments available, some patients are too ill to survive (The Intensive Care Society, 2008). Ultimately, the decision to continue active treatment or not rests with the ICU consultant, who will frequently discuss such decisions with other ICU consultants, the specialist referring team, the patient, their family/ carers/friends and other members of the multidisciplinary team (MDT). Lengthy discussions should take place with families, to ensure they are given the opportunity to ask questions in order to understand the rationale for care. They must also be assured that changing the focus of care from curative to palliative does not mean a ‘reduction’ in care or substandard care (The Intensive Care Society, 2008).

Campbell and Guzman (2003) claim that the best method to improve EoLC in ICUs is to define the goals of care before admission. However, they concede that it is uncommon for conversations to take place between physicians and critically ill people in need of ventilation/sedation. The use of advance decisions (ADs) is a recognised method of avoiding ambiguity regarding patients’ wishes. ADs have been recognised in America for some time, but are rarely encountered in UK hospitals at present. However, the Mental Capacity Act 2005 (MCA) came into effect in the UK in October 2007. It contains recommendations and stipulations for ADs. The AD must be specific to the treatment in question. The MCA states, ‘an advance decision is not applicable to life-sustaining treatment unless the decision is verified in a written statement.’ It is acceptable for clinicians to continue/ instigate care until they are satisfied that a valid AD exists instructing otherwise (George and Dimond, 2008). However, it is unlikely that individuals would be able to anticipate all scenarios and create an AD relevant to each possible event.

Informed decision-making

Rady and Johnson (2004) examined whether admission to ICU at the EoL is an informed process. They performed a descriptive, non-interventional study of 196 patients at a teaching hospital in America. They sought to identify clear decisions made between patients/ surrogates, i.e. relatives or next-of-kin, regarding aggressive therapy. In essence, they were investigating whether informed discussions regarding palliative care occur before ICU admission. They also assessed the impact of discussions on patient care and whether they led to aggressive therapy or better quality palliation.

Data were collected from medical records for all hospital deaths over 24 months. It was determined that 65% of deaths had occurred in the ICU. No patient transferred to the ICU, who subsequently died, had discussed palliation or EoLC as a treatment option. ICU patients underwent more invasive tests and were less likely to have adequate pain control or hospice referral than those who died on a general ward. Rady and Johnson ascertained that the EoLC was disrupted for patients with pre-existing, fatal, chronic illness when they were admitted to the ICU. This finding raises questions about the appropriateness of ICU admission for such patients.

Case scenario

Winnie, a 71-year-old woman, was admitted to hospital via accident and emergency (A&E) with a strangulated hernia requiring surgical intervention. On induction of anaesthesia, Winnie suffered cardiac arrest and spent some time without cardiac output. Once a sustainable cardiac rhythm was re-established, Winnie was transferred to the intensive care unit (ICU). The following day she underwent surgery, before returning to the ICU.

Post-surgical sedation was discontinued with the intention of weaning Winnie from mechanical ventilation. It became apparent, however, that Winnie had suffered hypoxic brain injury during the cardiac arrest. Although she was able to breathe spontaneously, there was significant neurological deficit. A computerised tomography (CT) scan of the brain was inconclusive. An electroencephalogram (EEG) demonstrated significant brain injury.

Winnie was a widow. She had four children and many grandchildren. Within the family she was a respected, central figure. The family needed information regarding how the brain injury had occurred, present and future management plans and likely prognosis. Unfortunately, conflict arose between family members and healthcare staff resulting from seemingly contradictory information being given to various family members by different healthcare personnel. The family developed a lack of trust of, and perceived lack of collaboration within, the healthcare team.

Communication breakdown resulted from nursing shift changes causing inconsistent care delivery. Lack of experience caring for patients such as Winnie and the need for communication skills training also contributed. The surgical team stressed to the family how successful the hernia repair had been, not acknowledging the severity of Winnie’s other medical problems, and creating a falsely, reassuring picture. Family discussions were inconsistently documented.

A more intense level of communication began only after the family complained. On investigation it appeared that uniform information had been provided, but it was misconstrued because of the use of ambiguous medical terminology. Winnie was eventually weaned from mechanical ventilation and no longer required invasive treatment. She was transferred to a medical ward. She died 2 weeks later from pneumonia.

It must be noted that the study relied solely on retrospective documentary analysis and all patient options may not have been recorded, i.e. documentation may have been poor and contemporaneous report writing not practised. Also, the study did not mention whether patients selected were already inpatients. This is relevant because emergency admissions rarely have the opportunity to discuss care options.

In an attempt to ascertain how ICUs in West Yorkshire, UK, approach EoL decision-making, Ravenscroft and Bell (2000) sent a postal questionnaire to clinical nurse managers. One section of this questionnaire focused upon decision-making relating to withdrawal of life-prolonging therapy, and consideration of when to withdraw life support. Interestingly, 11 of the 13 respondents perceived that active treatment was continued despite the nursing perception of treatment futility, suggesting that nursing opinion was not respected. Ravenscroft and Bell also discovered that no unit had any formal guidelines for withdrawal of life-prolonging medical interventions. Although six units regularly recorded the nursing estimate of the probability of dying, only three had data on the accuracy of these predictions (this was between 60 and 70% over a 12-month period). Eight respondents perceived that medical decisions on withdrawal of care were inconsistent, even when different patients had similar pathologies. This research demonstrates inconsistencies in practice at the EoL among healthcare professionals and patient groups, sometimes within the same disease group. Although simplistic, it provides a good basis from which to proceed with more detailed research. It would be interesting to recirculate an updated version of the questionnaire to discover the perceived standard of ICU EoLC, post-implementation of the NHS End of Life Care Strategy.

A landmark study, ‘The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT)’ occurred in 1995 (The Support Principal Investigators, 1995). This study was conducted in five teaching hospitals in America. The investigators’ objective was to improve EoL decision-making and reduce the frequency of mechanically supported, painful and prolonged death. The researchers undertook a 2-year, prospective, observational study (phase 1) with 4301 patients, followed by a 2-year controlled clinical trial (phase 2) with 4804 patients. The physicians were randomised by specialty, e.g. cardiology, respiratory, etc., to an intervention group. In the intervention group, estimates of the likelihood of 6-month survival for every day up to 6 months, outcomes of cardiopulmonary resuscitation (CPR), and functional disability at 2 months were generated. The intervention took the form of a specifically trained nurse who had multiple contacts with the patient, family, physician and hospital staff to elicit preferences, improve understanding of outcomes, encourage attention to pain control, and facilitate advance care planning and patient–physician communication. Patients in this group had to have one or more life-threatening diagnoses.

Findings for phase 1 included ‘shortcomings in communication’ and ‘frequency of aggressive treatment’. It was elicited that only 47% of physicians knew whether their patients preferred to avoid CPR. A total of 38% of the patients that died spent at least 10 days in the ICU. During phase 2 of the research (intervention group) it was noted that the patients did not experience any improvement in patient/ physician communication. Furthermore, the intervention had little impact upon the five outcomes targeted within the research and clinical area. The five targeted outcomes are listed below:

  • ▶▶ Incidence of timing of CPR orders, i.e. the decision not to resuscitate and when that decision occurs

  • ▶▶ Numbers of days spent in ICU

  • ▶▶ Physicians’ knowledge of their patients’ preferences not to be resuscitated

  • ▶▶ Reviewing mechanical ventilation

  • ▶▶ Level of reported pain.

In their conclusions the authors confirm that the phase 1 observation of SUPPORT demonstrated substantial shortcomings in care. Additionally, phase 2 failed to improve patient outcomes. The main limitation of this research is its age. There have subsequently been advances in care in this clinical arena. Further work is required to establish areas still in need of development. A British study would be of great interest, in view of the differences between private and public healthcare systems in the UK and USA.

Communication is fundamental to all aspects of health care and can only enhance delivery of care. In the SUPPORT study, communication did not significantly alter the findings as an isolated improvement measure. However, regular communication with patients, carried out by practitioners skilled in the use of structured communication between all disciplines using an integrated care pathway, may have provided more positive results. Communication with relatives early on in a patient’s admission to the ICU is an integral part of care (not just for people at the EoL). Establishing a rapport with the patient/relatives should not wait until critical issues arise.

To address shortcomings and improve family communication at the EoL in ICUs, Ahrens et al (2003) undertook a study that involved the use of a communications team composed of a physician and clinical nurse specialist. This American work was conducted over a period of 1 year. The objective was to examine the impact of improved communication on length of stay and costs for ICU patients near the EoL. A total of 151 patients were split into two groups. They were then randomly divided and the communication they received was either the unit ‘standard’ (control group) or that provided by the physician and clinical nurse specialist (intervention group). The findings confirmed that timely, coordinated sharing of vital information affects patient outcome. The intervention group had significantly shorter stays in the ICU (and hospital) resulting in lower costs.

The researchers acknowledged the need for relatives to have time to process significant information. This was supported by improved interaction and involvement of healthcare professionals dedicated to discussing the patients’ and relatives’ concerns. This enabled families to make earlier, collaborative, and informed decisions. Despite the apparent economic motive behind this research it raises issues about the importance of effective communication. However, the authors did not delineate their usual standard unit communication practice. This makes it difficult to ascertain which aspects of the actions of the communications team made the most difference.

Kirchhoff et al (2002) found that paucity of communication from healthcare providers contributed to the anxiety and distress reported by patients’ families. Their qualitative study focused on two issues: (a) the experience of family members of having a relative who died in an ICU, and (b) family expectations before and immediately after the death. Their results show that uncertainty coloured all respondents’ experience. Many continued (even months after the death) to wonder whether they had made the right decisions about allowing their relatives to die by agreeing with critical care staff to discontinue active treatment. These findings give rise to concerns about the effectiveness of conversations with families regarding decision-making in ICUs.

Heyland et al (2003) conducted similar research in Canada. Their objective was to describe the perspectives of family members regarding the care given to critically ill patients who died in ICUs. They undertook a prospective, observational, multicentre study in six university-affiliated ICUs. Selection criterion was those patients who received mechanical ventilation for more than 48 hours and then died in the ICU. Three to four weeks after death, a questionnaire was sent to one selected family member. Of 413 questionnaires sent, 256 responded (62% response rate). In contrast to Kirchhoff et al (2002), the findings of Heyland et al reflected satisfaction amongst the majority of family members with regard to adequate communication, good decision-making, respect and compassion. It is perhaps pertinent to note that the majority of participating ICUs had support services from social workers, which may have meant an increased level of dialogue with families.

Intensive care nurses’ experiences of caring for dying patients

Nurses are most often present with individuals at the end of life. It is essential that they are knowledgeable about the provision of EoL and palliative care (Robinson, 2004). Critical care nurses face the dilemma of initially trying to prolong life and then, when futility is apparent, having to redefine their care, responding to the needs of the dying patient and their loved ones (Pattison, 2004). This redefinition of care is often done without any formalised palliative care training. Yet critical care nurses are ideally placed to be facilitators of good EoLC because such nurses are very patient and family-focused as a result of providing one-to-one care.

Much literature surrounding critical care nurses and EoLC mentions conflict between nurses, physicians, families and other nurses. This has been attributed to the complexities of many individuals working together, each with their own values and experiences (Jezuit, 2000). Such conflicts may lead to unsatisfactory outcomes for patients/families.

Oberle and Hughes (2001) conducted research to examine doctors’ and nurses’ perceptions of ethical problems of EoL decisions. Ethical problems can be a source of tension for healthcare professionals. It is therefore important to understand the perspectives of others. The researchers, both Canadian nurses, used qualitative methods to interview seven doctors and 14 nurses, all of whom worked in acute areas (including the ICU). Respondents were asked to describe ethical problems frequently encountered in practice. Findings showed that all participants experienced ethical problems around decision-making at the EoL. The ‘core’ problems for doctors and nurses included witnessing suffering and uncertainty about the best course of action for the patient and family. The responses of the subjects suggested a lack of interdisciplinary collaboration and differences in perception between doctors and nurses as a result of different professional roles. These findings imply a need for greater communication and training.

Jezuit (2000) undertook a pilot study to examine the suffering of critical care nurses in relation to EoLC decisions. Semistructured interviews were conducted with a sample of six respondents (five female and one male), all with a minimum of 1 year’s experience in critical care. The subjects had responded to an advertisement seeking critical care nurses who experienced suffering in their role. This clearly attracted those who viewed their experience as ‘suffering’ and could have led to sampling bias. Those who did respond identified feeling stress, frustration, anxiety and anger. Inadequate support from medical staff was also reported. Lack of collaboration between medical and nursing staff was a common theme in the research. Nurses also stated a lack of consideration for the patient (from the family and medical staff) in that patients were kept alive via mechanical ventilation or pharmacological intervention longer than they should have been. All nurses reported the existence of conflict within the multiprofessional team and between the family and professionals. The nurse was perceived as the central figure in all interactions involved in EoL decision-making.

Badger (2005) used focus groups and interviews to explore the coping mechanisms of ICU nurses during transition from curative to palliative care. The study was undertaken in an American ICU and included 24 participants (19 female and five male). The results provide a more positive reflection of nurses’ experiences. Badger subdivided the coping strategies that nurses displayed:

  • ▶▶ Cognitive coping strategies, i.e. visualising, learning from experience and putting things into perspective

  • ▶▶ Affective coping strategies: externalisation of feelings, e.g. expressing thoughts or feelings and ‘emotional compartmentalisation’, i.e. defence coping mechanism involving suppression of unpleasant emotion

  • ▶▶ Behavioural coping strategies: these strategies included retreating from patient care.

Yang and McIlfatrick (2001), in their phenomenological study undertaken in Taiwan, found that nurses commonly cited the provision of what was deemed ‘futile’ care to be the most distressing aspect of care. Participants spoke of the notion of ‘torturing the patient’. Rationale for continuing to treat the patient was cited as being for the benefit of relatives who were unable to let their loved one die, and for medical staff who were unable to be completely honest with the family about the inevitable outcome. Yang and McIlfatrick acknowledged the paucity of research relating to experiences of nurses providing EoLC in critical care environments (particularly in comparison to nurses caring for patients in cancer settings).

When researching Australian nurses’ experience of withdrawing/withholding treatment in the ICU, Halcomb et al (2004) discovered inconsistencies, tension and conflict between healthcare professionals. In this phenomenological study, the authors interviewed 10 nurses. The intention was to increase awareness among other healthcare professionals regarding ICU nurses’ experiences caring for patients who had treatment withdrawn or withheld. Five main themes emerged (Table 1).

Table 1

Caring for patients who had treatment withdrawn or withheld (themes)

Tension was evident within the participants’ narratives, all of which expressed conflict regarding their role in decision-making to some extent. In one nurse’s experience, doctors excluded nurses from decision-making and formulation of the management plan, but once a decision was made to forego medical treatment, nurses were left to manage the dying process. Throughout the reviewed research, this issue regularly surfaces as an area of personal and professional struggle for nurses. Evidence clearly demonstrates that nurses caring for EoL patients in ICUs are constantly faced with tension and conflict with colleagues and within themselves.

However, there is potential to improve the care given to EoLC patients and their families in ICUs (as well as the experiences of the critical care staff) via implementation of an adapted EoL integrated care pathway.

Implementing an EoL integrated care pathway for dying patients within ICUs

An integrated care pathway is a ‘tool’ for identifying, evaluating and then modifying the process of care delivery. It facilitates continuous improvement in the quality of patient care and provides a mechanism to review the process via audit (Johnson, 1997). It integrates national guidelines for best practice into one document (Mellor et al, 2004) and enables staff to spend less time on paperwork (Campbell et al, 1998). The Liverpool Care Pathway for the Dying Patient (LCP) was developed for dying cancer patients, based on gold standard, hospice level care for terminally ill and dying people (Ahrens et al, 2003). It soon became apparent, however, that it could be used for patients with any condition. The LCP provides evidence-based guidance to enable doctors and nurses to deliver high-quality care to dying patients and their relatives. It facilitates multiprofessional communication, documentation and care planning. Pioneers of the LCP at the Marie Curie Palliative Care Institute Liverpool have adapted the pathway for ICU patients.

A major difficulty in generic and critical care areas is recognition that a patient is approaching the end of their life. This is complicated further for patients who may be sedated and ventilated. The general criteria for commencing the pathway are:

  • ▶▶ The multiprofessional team has agreed that the patient is dying

  • ▶▶ All possible reversible causes for the current condition have been considered

  • ▶▶ Two of the following conditions must apply: the patient is bed-bound; only able to take sips of fluid; or semi-comatose and no longer able to take tablets.

For ICU patients, the criteria are similar, in that the multiprofessional team must agree that the patient’s condition is non-recoverable, and all possible reversible causes have been considered. A discussion with the referring team should then occur and they must agree that the patient is dying. Implementation of the LCP in the critical care environment will not remove the difficulties in recognising that a patient is approaching the end of life. As a single measure it is not the total answer to better care provision for patients dying in ICU. However, it is hoped that increased awareness of the LCP, and the training that its implementation requires, will prompt earlier and improved discussions between staff and the patient/family.

Figure 1 shows ‘extracts’ from an example document for use in ICUs, developed by the Marie Curie Palliative Care Institute Liverpool. The Institute emphasises that the LCP should be adapted for local use. Adjustments to the text, format and goals can be amended as necessary (Murphy, 2003). It is a multiprofessional document and should replace all other documentation. Any deviation from the plan is documented as a ‘variance’. A criticism of the use of care pathways has been that by standardising patient care it becomes less individualised (Campbell et al, 1998). However, vast inconsistencies in EoLC in ICUs as detailed in this article support the requirement for some standardisation of care. It is the variances (when used correctly) that facilitate individualised care of the patient and their family.

Figure 1.

Extract from ‘Care of the Dying Pathway (LCP): Hospital Intensive Care Unit’. N.B. These are only extracts. Permission to reproduce granted by the Marie Curie Palliative Care Institute Liverpool (www.mcpcil.org.uk). Supporting references for pathway: Ellershaw and Wilkinson (2003); The National Council for Palliative Care (2006). IV = intravenous; S/C = subcutaneous; DNAR = do not attempt resuscitation.

An ICU-specific EoLC pathway may improve the disjointed and inconsistent care currently received by people who are dying in ICU. The Marie Curie Palliative Care Institute has developed a ‘10-step’ implementation process for the LCP (Ellershaw and Wilkinson, 2003). Elements of this programme can be translated into use within the critical care environment and would serve as a useful resource. The Institute will support and aid teams/units in the implementation process. Appropriate funding, allocation of dedicated time and resources and strong leadership are crucial to the effective implementation and sustainability of an EoLC pathway. This is a challenge in a busy and stressful working environment; however, it is an important part of overall patient care in view of the NHS End of Life Care Strategy.

Recommendations

  • ▶▶ A knowledge gap exists in the education of critical care nurses. If hospital trusts want to improve standards of care, the experiences of patients and their relatives, staff retention and morale, investment is needed to train staff in EoLC. Further education and training could make nurses feel more confident as they strive to meet the complex physical, psychological, social and spiritual needs of dying patients and their families.

  • ▶▶ In order to combat the lack of collaboration between doctors and nurses, multiprofessional training in advanced communication skills and group debriefings to encourage flow of information and an alternative perspective should be implemented. This will not radically change the current system but could provide a suitable platform upon which to begin.

  • ▶▶ The LCP is a useful a tool for the implementation of EoLC in the ICU. The key to its success will be the time/money/resources invested in its introduction.

  • ▶▶ Nurses and doctors must recognise the need for change in the focus of care from curative to palliative and become adept at providing good quality EoLC to patients and their families in the ICU.

  • ▶▶ Investment needs to be made in the provision of a supportive network for all staff working in this area (not just nurses) to improve retention of staff, reduce sickness rates and enhance job satisfaction.

Conclusions

The evidence discussed in this article suggests that EoLC in ICUs is variable. Whether in a UK, North American or European unit, the difficulties faced are uniform, in spite of differences in healthcare systems and training. Variability in care does not automatically imply poor quality care, but is suggestive of a lack of consensus among critical care clinicians. Quality of care can be improved for patients, a significant proportion of hom receive care that is not consistent with their wishes. It is hoped that use of an integrated care pathway for the dying ICU patient will provide a structure to maintain and evaluate care with measurable goals. The impact on patient care and the support of relatives is the most important aim of introducing the LCP in ICUs. Thorough, objective evaluation is needed.

Useful resources

European Society of Intensive Care Medicine http://www.esicm.org/index.asp

Liverpool Care Pathway for the Dying Patient Central Team http://www.mcpcil.org.uk/contact_us/contact_the_lcp_central_team_uk

The Intensive Care Society http://www.ics.ac.uk/index.asp

The Marie Curie Palliative Care Institute Liverpool http://www.mcpcil.org.uk/

Key Points

  • ▶▶ Although intensive care was originally conceived to provide vigorous technological treatment for patients, the mortality rate in intensive care units (ICUs) can be 20–30%.

  • ▶▶ ICU standards of care and decision-making at the end of life are often inconsistent, even within the same unit, causing tension between members of the multidisciplinary team (MDT) and between the MDT and families.

  • ▶▶ ICU nurses are the health professional most often present with patients and families at the end of life in the ICU environment. It is essential that they are knowledgeable about palliative and end-of-life care.

  • ▶▶ Staff members in ICUs require education regarding recognising dying and communication with families.

  • ▶▶ Introducing an integrated care pathway such as the Liverpool Care Pathway for the Dying Patient may be beneficial in ICUs to engender uniformity of care.

Erratum notice

An error occurred in ‘Legal aspects of the case scenario’ (End of Life Care 2(2): 17).

Under the heading ‘Ascertaining the best interests of Mrs S’ the text should have read: ‘It is important to ascertain, not their [the relatives’] views as to what should take place, but any information which they can give about: Mrs S’s [the patient’s] past and present wishes and feelings; the beliefs and values that would be likely to influence Mrs S’s decision if she had capacity; and the other factors that Mrs S would be likely to consider if she were able to do so.’

The word ‘not’ had been omitted.

The important point is that it is the patient’s views that are important in determining best interests, not the views of the relatives.

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