Running head: CRITICAL CARE NURSING: END OF LIFE CARE 1

Critical Care Nursing: End of Life Care

Angela M. Facer, WCSN

Westminster College
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End-of-life care (EOLC) is when all the possibilities of recovering have been exhausted,

also known as terminality. Terminality can be defined as progressed conditions with the

foreseeable likelihood of death. The patient is approaching death without the possibility of

recovery. However, health practices and technology have improved in the control and treatment

of diseases in the twentieth century. Innovations in technology, while progressive, have brought

their own ethical decisions about how to conduct one’s self during a terminal illness which adds

moral distress to critical care nurses (Costa et al., 2014).

Traditionally, the intensive care unit (ICU) centered around curative care for patients.

Some patients will fully recover, some will be left with life-long chronic illness, and

devastatingly some will die. Critical care is an environment that supports cure and cares for the

dying. EOLC places focus on preventing and relieving pain while providing the best quality of

life possible during the transitional stage to death. With this focus it is immensely important to

support the patient and family’s spiritual and emotional needs as this goes hand and hand with

this painful process (Crowne, 2017) . This process of EOLC can be mentally draining on the

patient, families, and healthcare staff. Because of this it is essential to watch for caregiver

burnout which is the state of emotional and physical exhaustion caused by the continued stress

of caregiving. Identifying this type of exhaustion is imperative to ensure that the patient receives

competent and ethical care.

The ICU is where severe trauma and near-death patients are admitted to receive life-

sustaining support. Because of this, Costa et al., (2014) described the ICU as “Most deaths occur

in hospital ICUs due to the severity”. Because there is a high mortality rate within the ICU, there

is a feeling of trepidation that follows. Holms et al., (2014) states that “95% of patients in ICU

may not have the ability to make informed decisions regarding their care due to their illness or
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sedation.” When families and patients seek recovery, it is challenging to initiate an EOLC

approach when they receive notice of these conditions. Nevertheless, when treatment is no

longer effective, the ethical and moral approach as health care providers is to transition from

curative care to EOLC, which could be rapid or prolonged depending on the progression of the

disease.

EOLC involves many different aspects of critical thinking by involving many different

aspects of professional care. One of the ways to provide competent evidence-based practice is to

implement interventions that follow symptom management, personal care, emotional,

psychological, and spiritual support. By providing this type of care the healthcare provider can

ease the pain and suffering involved. Because of the significance that EOLC brings, healthcare

providers should critically think about challenges patients and families might face regarding the

decision to withdraw life-sustaining support, barriers to providing EOLC and factors that support

EOLC. Noome et al., (2017) stated that using these tools “healthcare professionals can ease the

pain and suffering by prioritization of communication between staff and family which can help

with this emotional process of EOLC.”

Overall, there is a lack of research supporting EOLC that is being used currently in

practice. Many articles state the importance of a dignified death, but the literature was lacking in

specific steps and interventions. Crown (2017) reflects this lack of literature on EOLC, stating,

“There is literature available to help guide healthcare professionals in making the decision to

withdraw life-sustaining support, including considerations of ethical implications, and the

involvement of families. There were also recommendations for what is considered appropriate

EOLC and what are perceived as barriers”. Throughout the research there were many types of

checklists that could potentially be used to help frame a proper process when dealing with
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EOLC. Because of the magnitude of this situation, it should never land on one person to carry.

Below is a table that could be helpful when EOLC is impending which was retrieved from The

Canadian Journal of Critical Care Nursing (Crowne, 2017).

Table 1: ICU Withdrawal of Life-Sustaining Therapies Bedside Nursing Checklist

ICU Withdrawal of Life-Sustaining Therapies Checklist Yes/No Comments
Decision Making
1. Does the patient have a living will, an advance directive, enduring Power of Attorney for health
issues?

If YES, is the proposed decision to withdraw or withhold life-sustaining therapies in accordance with
the available information?
2. Has a multidisciplinary team meeting occurred to discuss the plan for withdrawal of life-sustaining
therapies?

If YES, ensure meeting information is documented in the patient’s chart.

3. If the patient is able, has he/she been involved in the decision-making process?
4. If the patient is not capable, or is unconscious, has the next of kin/substitute decision-maker been
involved in the decision-making process?
5. Has a family meeting occurred? The family should be involved with the initial and ongoing
decision-making. Have follow-up meetings occurred with the family?

All meetings are documented in the health record by all professionals involved (e.g., physicians,
nurse, and social worker).
Preparation
6. Has the option of organ and/or tissue donation been offered to the family (including eye bank
referrals)?
7. Has the physician communicated the plan of care to the family?

Orders are written, or a signed copy of the ICU Withdrawal of Life-Sustaining Therapies pre-printed
orders is on the patient’s chart.

Updated code status documentation is on the patient’s chart.

All members of the health care team involved in the patient’s care are aware of the change of care
focus.
8. Has the family been offered spiritual or religious support? And, if yes, have the appropriate people
been notified?
9. Have family preferences with regard to presence during the withdrawal of life-sustaining therapies
been identified, documented, and planned for?
10. Have family requests for interdisciplinary supports (e.g., social worker) during the withdrawal of
life- sustaining therapies been identified, documented, and arranged?
11. Have the patient and/or family had the opportunity to speak with a spiritual resource person if
requested?

Are there any specific religious/cultural practices or other special requests to be followed prior to,
during, or at the time of death?
Implementation
12. In preparation for the withdrawal of life-sustaining therapies please ensure:
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1) If able, move the patient to a private room.

2) Ensure patient is clean and comfortable (allow family to participate in final care if desired)

3) Prepare the room. (Remove as much technology / equipment from the room as possible; ensure
adequate chairs for family members; ensure tissues available to family; dim lights)

4) Turn off bedside cardiac and ventilator monitor alarms (either remove entirely or change to
central monitoring only)

5) Allow for special requests (e.g., favorite blanket to be placed on patient, music, etc...)
13. Have all comfort measures been implemented?
Have all other non-comfort treatments been discontinued?
14. During the withdrawal of life-sustaining therapies, the nurse will frequently monitor the patient
for signs and symptoms of distress (pain, anxiety, or other), and adjust medications accordingly.
Document in the nurses’ notes.

During the withdrawal of life-sustaining therapies the nurse will communicate frequently with family
members present to ensure their comfort, and their perceived comfort of the patient, and respond
accordingly.

Integrating something similar like the table above could significantly help healthcare

professionals when dealing with a sensitive process such as EOLC. It provides many positive

implications such as improved quality of life, more effective management, less paperwork and

decreased moral distress on healthcare professionals. EOLC is something all healthcare providers

will be presented with during their career. There needs to be more evidence-based research to

show how different interventions can improve or adversely affect the patient’s or their family’s

experiences while in the ICU.

Although ICU care traditionally focuses on curative care, there is an increasing

awareness of the importance of EOLC. Being prepared for this sensitive situation is crucial to

positive support from staff and families. Brooks et al., (2017) explained how communication

could “improve decision-making practices regarding initiating EOLC in the ICU. Clear

organizational processes that support the introduction of healthcare providers are essential to

achieve the best possible outcomes for patients and patients’ family members.” Advancements in
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research should focus on communication of healthcare providers along with family.

Collaborating together is a way to provide a supportive decision-making framework for EOLC.

This information provides insights into the practices and understandings of healthcare

providers caring for their patients and families during EOLC. Based on the information stated

above there is a need for improved research, skills, and training related to EOLC. Every patient

at the end of their lives should be provided with high-quality, compassionate and dignified care.

By furthering research and understanding of the complexity of EOLC in ICU healthcare

providers can work together towards a positive dignified EOLC.

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References

Brooks, L., Manias, E., & Nicholson, P. (2017). Communication and decision-making about end-

of-life care in the intensive care unit. American Journal of Critical Care, 26(4), 337-341.

Browning, A. (2013). Moral distress and psychological empowerment in critical care nurses

caring for adults at end of life. American Journal of Critical Care, 22(2), 143-151.

Costa, T., Dias, J., Oliveria, A., Rodrigues, F., & Monenegro, S. (2014). End of life and palliative

care in ICU. Journal of Nursing, 8(5), 1157-1163.

Crown, S. (2017). End-of-life care in the ICU: Supporting nurses to provides high-quality care.

Canadian Journal of Critical Care Nursing, 28(1), 30-33.

Holms, N., Milligan, S., & Kydd, A. (2014). A study of the lived experiences of registered nurses

who have provided end-of-life care within an intensive care unit. International Journal of

Palliative Nursing, 20(11), 549-556.

Noome, M., Kolmer, D., Leeuwen, E., Dijkstra, B., & Vloet, L. (2017). The role of ICU nurses in

the spirtual aspects of end-of-life care in the ICU: An explorative study. Scandinavian

Journal of Caring Sciences, 31(3), 569-578.

Pattison, N., O'Gara, G., & Wigmore, T. (2015). Negotiating transitions: Involvement of critical

care outreach teams in end-of-life decision making. American Journal of Critical Care,

24(3), 232-240.