For the next in our intensive care and palliative care series, Pål Klepstad, ICU medical director and professor in Norway, reflects on who should be making decisions about whether intensive care treatment is in a patient’s best interest.
For patients and their relatives, admittance to the Intensive Care Unit (ICU) is abrupt, dramatic and usually life-threatening. Treatment involves invasive procedures, often sedation, and patients are attached to monitors, intra-arterial cannulas and central intravenous lines (IV). ICU treatment is often painful for patients, physically and psychologically. For relatives, it represents an acute crisis and, in many countries, a significant financial burden for them. Moreover, even in rich countries ICU therapy can be a limited resource due to lack of capacity, including having enough qualified ICU nurses.
This raises the need for end of-life discussions. Here are two patients from my own department:
Male patient with Chronic Obstructive Pulmonary Disease (COPD) is admitted to hospital. He has really bad lung test results, muscle wasting and general ill health. The patient is not admitted to the ICU because his short-term prognosis is poor, and we will only add to his suffering with ICU therapy.
Female patient who is immunocompromised. She has cancer, is sedated and on a ventilator due to pneumonia. She is admitted to ICU but despite broad-spectrum antibiotics, she has increasing organ failure. Life prolonging treatment in ICU is stopped.
There is one important question – who should decide if ICU treatment is given?
Surely the patient should decide, as a patients’ autonomy is absolute? In Norway, the answer is actually both yes and no. Yes, because the patient can refuse to receive treatment. They can tell health care staff that they are ready to let fate happen and do not want to suffer any more from their illness. On the other hand, the patient cannot request treatment that the physicians consider futile. The ethical argument for this is that the physician’s duty is to do no harm. The physicians knows that intensive care therapy can inflict pain and anxiety without improving survival and is obliged to spare the patient this suffering. The problem is not always so clear cut though, as some patients and relatives may have a different threshold for what they would consider futile, compared to a healthcare professional. For instance, is a 20 % chance to achieve three months longer survival worthwhile to inflict pain to a patient and to use health care resources? Importantly, unneeded ICU therapy given to one patient means that other patients risk not receiving intensive care if they can’t be admitted to ICU due to lack of healthcare capacity.
Many ICU patients are too incapacitated to be able to understand and decide on their care. So, should relatives decide? Patient’s relatives cannot request treatment that the ICU physicians consider futile. What they may be able to do is tell us what the patient may have wanted to happen.
What about the society deciding? On one level, society does decide. The society decides the magnitude of ICU delivery – a society that does not adequately finance the staffing of ICU departments decides to let some patients with treatable condition die. Thus, even if there is no direct participation in individual cases, the society decides the framework into which ICU physicians have to prioritise who can receive intensive care.
To summarise, the decision to give or withdraw life sustaining ICU therapy is based on the patient’s prognosis. Some hope for survival can mean that ICU therapy will be started, and no hope of survival means that ICU therapy is unethical, both in respect to the actual patient, to other patients’ access to ICU and to the society. For the latter group, the patients are better to be offered good end-of-life care. End-of-life care can be given by intensivists within the ICU, in specialised palliative care units, or in general wards, as appropriate for each individual patient and for each hospital’s organisation. Irrespective of the setting where patients receive care, the best treatment is often based upon collaboration between the various involved medical healthcare staff.
Ideally, for those with chronic diseases – and perhaps even for those who haven’t – a discussion about potential ICU care should take place before the onset of acute critical illness. As well as with the patient, an advanced care plan discussion can include relatives, general practioners and relevant hospital specialist physicians. In the acute setting, in-depth knowledge of the patient’s acute disease, chronic illnesses, frailty, organ failure and ICU treatment options is needed to evaluate a patient’s prognosis. Knowing the patient’s wishes as well, means a clear decision can be made.
In clinical medicine, this combined knowledge primarily belongs to the ICU specialist. Does this make the ICU specialist a sort of god-sent person who decide who should live and who should die? No, that is fate – or perhaps, for religious persons, higher forces that decide. However, often the ICU physicians are in the best position to interpret what fate has decided.
Links and resources
Read the other blogs in the EAPC’s Palliative Care and ICU series here.
About the author
Pål Klepstad is an intensivist working within ICU care for the last 30 years. He has also been involved in research in palliative medicine, in particular, topics related to opioid pharmacology and symptom control. He is one of the authors of the Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Orcid: 0000-0003-2804-8447.
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