Jeffrey Farber, MD, Brookdale Department of Geriatrics and Adult Development Mount Sinai School of Medicine, New York, NY, USA.
An educational video entitled “Compassionate Care in the ICU,” funded by Ortho Biotech and produced by the Society of Critical Care Medicine, aims to improve end-of-life care for patients dying in the intensive care unit (ICU). It is a well-paced, well-filmed video that alternates between advice and opinions from experts in the field of critical care, and poignant, still, black-and-white and colour photographs of common scenes in the ICU. There are two distinct videos: a shorter version intended for professional use, and a second for families of patients being cared for in the ICU. While overlapping in core content, there are significant differences between the two.
The professional video begins with recognition by experts that good communication is both lacking and needed in the ICU. Common barriers to effective communication are discussed, such as deficiencies in the physical environment, physician-family misunderstandings and conflicts, and the paucity of formal staff training in communication skills. Specific examples, such as noise, bright light, and a busy and fast-paced environment are noted, but advice on how to deal with these impediments is lacking. While the video stresses the importance of listening, of “putting down your stethoscope” and “being with a dying patient,” it does not sufficiently address how to establish goals of care with a patient’s family. Indeed, the term “goals of care” is not introduced until the very end of the 25-minute video.
The professional video does a nice job of discussing the need to guide families through the transition from the aggressive, curative approach of a critically ill patient to the symptom-focussed, palliative care approach. It clearly highlights the importance of treating the patient-family unit and credits the physician’s role in providing good palliative care. A highlight of the video features an ICU physician clearly explaining the necessary skills involved in organizing and carrying out an effective family meeting, from preparation to finding a quiet setting, to having a focussed agenda and summarizing and establishing a clear follow-up plan for the family. This is followed by another expert’s recommendation to have physicians train to communicate via professional actors playing family member roles.
While the video makes a convincing argument for the need to better care for dying patients in the ICU, it unfortunately fails to touch upon common specific scenarios that would help its intended audience. Shifting from a curative to a palliative approach often occurs in stages over time. The best tool to help this transition along is a clear and frank discussion of the goals of care. When it becomes clear that the goal is comfort, then the plan of care needs to be reviewed and revised so that all interventions and therapies accord with this goal of care. It is common for clinicians and families to decide together for example that no further blood draws or diagnostic radiographic imaging be performed. Likewise, commonplace, almost standard, ICU monitoring such as telemetry, urinary catheters, and continuous intra-arterial blood pressure need to be reviewed and discontinued if not achieving the goals of care. Unfortunately, there is not one photo in the video of an ICU patient that is not connected to a telemetry monitor and various intravenous catheters.
Likewise, the option of having dying patients transferred out of the ICU to a more appropriate setting is not mentioned. As one clinician described in the video, ICU care is best considered a “therapeutic trial” of a clinical strategy. When this trial fails, then one valid option is to transfer the patient out of the ICU setting to an environment where the goals of care can be better achieved. The ICU is indeed a busy and fast-paced environment with an invasive and aggressive approach to curative care, and it is not feasible to expect the professionals working there to easily shift gears and embrace and excel in providing expert palliative care. While it is important for intensivists to acknowledge the importance of palliative care and good communication skills, it is also important to recognize that optimal end-of-life care more often and readily occurs outside of the ICU setting.
While the expert opinions and still photos are effective, what’s missing in this professional version of the video are the personal and the patient-family unit’s voice. There is no physician account of a specific memorable case, nor a deceased patient’s loved one discussing her experience with end-of-life care in the ICU. This stands in sharp contradistinction to the more touching and personal family version of the video.
In the family version of the video, similar issues such as good communication and the importance of effective symptom management are well-addressed. In addition, establishing goals of care through ongoing communication over time is much better emphasized. There is a wonderfully moving account by a critical care physician of a previously healthy patient who became quadriplegic and ventilator-dependent after a motor vehicle accident. He expertly describes the patient’s eventual transition to palliative care, removal of mechanical ventilatory support, and dying with his family present, drinking a glass of red wine, and being kept free from dyspnea with the appropriate administration of morphine. There is a similarly well-done piece discussing the importance of advanced care planning, specifically highlighting the need to designate a health care proxy and to discuss with the proxy what is an acceptable functional state and quality of life.
The family version does a much better job of clearly stating that there is always something we as professionals can do for patients, that withholding life support does not equal withholding care, and that technologies can be correctly described as death-prolonging as opposed to life-extending when used inappropriately. Families are encouraged to initiate conversations with critical care staff and are assured that dying does not have to be painful nor isolating. There is an effective scene of a critical care expert advising family members on how to achieve closure with a dying loved one. She specifically addresses forgiving the dying person, asking for forgiveness, saying, “I love you,” and then saying goodbye. Likewise, there is a powerful still black-and-white photograph of a patient in the ICU sitting up in a chair with a neck dressing covering what is likely a recently discontinued central venous catheter, shaking hands with a physician. This photo masterfully shows the potential of the ICU to be a place where a person can die a good death. Nearly all that is lacking in the professional version exists in the family version. I would advise critical care units to use both versions to help educate staff to improve care for dying patients and their loved ones.
