INDIVIDUAL ASSIGMENT

CRITICAL NURSING COURSES

TREND AND ISSUE ABOUT END OF LIFE IN ICU

SUPPORTING LECTURER:

Wenny Trisnaningtyas, S. Kep, Ns, M. Kep

ARRAGED BY:

Name : Rizka Yuliasih Kussanty

Nim : P1337420620039

Class : 3A3 RKI

BACHELOR OF APPLIED NURSING IN SEMARANG

NURSING DEPARTEMENT

HEALTH POLYTECHNIC OF HEALTH MINISTRY SEMARANG

2023
 TREND AND ISSUE ABOUT END OF LIFE IN ICU

End-of-life care is a global concern. During EOL care, many patients experience life
events, where they have insufficient control over important changes in their lives leading to
confusion. Nurses are well-versed in the physical and psychological conditions and
preferences of their patients and hence, must cope with these complex needs. Critical care
nurses play an integral role in supporting older patients and their families facing the EOL
care decision-making challenge. Despite national imperatives to improve the quality of EOL
care, patients continue to experience uncontrolled pain, inadequate communication, and life-
sustaining treatment against their will (Kim et al., 2021).

In the Intensive Care Unit patients are submitted to sophisticated treatments in order
to support organ failure while specific therapies are administrated in an attempt to
definitively control the disease. Unfortunately, this goal is not always obtained and despite
great improvements in the care of critical patients, death is frequent in the ICU setting and is
often preceded by decisions to forego lifesustaining treatments (Consales et al., 2014).

A high percentage of patients die in the ICU, often after a prolonged period of illness
and being unable to make decisions for themselves. Timely communication about life
expectancy and endof-life care is crucial for ensuring good patient quality-of-life at the end of
life and a good quality of death. In such conditions, the responsibility for these decisions falls
upon clinical staff and patient's relatives. The decision making process must be aimed to
choose amongst treatment options trying to meet patients and families' wishes and "shared
decision making" is now considered as the best practice in dealing with the EOL dilemmas in
the ICU. Ensuring the autonomy consists in respecting the selfdetermination of patients and
supporting them such that they can make their own decisions, as many times as it is possible.
Beneficence refers to providing potential or actual benefits to patients, whilst non-
maleficence is a broad concept including active and passive measures .

EOL choices can be subdivided into two broad categories. Choices are
"unconstrained" when multiple treatment options are available and limited only by clinical
standards and patient's preferences. On the other hand, sometimes choices can be
«constrained» due to unavailability or to inherent impossibility to work. The latter cases of
constrained choices imply many ethical problems. Indeed, unavailability of treatment options
must be limited by the adoption of good clinical practice criteria, mainly standard admission
and discharge criteria and expediting bed flow. Doing so, the need for rationing or «allocation
of health resources in the face of limited availability» can be dramatically reduced. Triage is
required when needs exceed supply, in order to provide the best to everyone who needs,
relying upon objective and transparent criteria of priority.

Intuitively, every decision made in the ICU is dramatically influenced by the

prognostication of the patient's outcome. Assessing the prognosis is the first step of decision-
making, so strong efforts must be made in order to establish the chance of overcoming the
critical illness, the presumed length of survival and the quality of the remaining life.
Unfortunately, establishing the outcome of the critically ill is often impossible, even when
objective scoring systems are adopted. Moreover, the reliability of the prognosis needs to be
carefully established and when high uncertainty persists, it must be frequently reassessed.
After clarifying the prognosis, ICU clinicians need to share responsibility in a
multidisciplinary approach and then must assess relatives' preferences regarding their role in
the decision-making process.

Adequate communication with families is of course of paramount importance in order

to alleviate suffering and to make the wisest choice in the best interests of the patient. Then,
reciprocal confidence between staff and family contribute to the reduction of legal conflicts.
Communication practices vary with country, and when the backgrounds between the
healthcare professional and patient differ, communication and decisions about care can
become difficult. Misunderstanding and misinterpretation of information can occur amongst
cultural groups because of different beliefs, practices, and language barriers. Communication
is also critical because access to information and treatment options seem to be limited for
some cultural groups, particularly if they do not speak the national language. An
understanding of the underlying reasons involved in the attitudes and choices of cultural
groups could improve EOL communication and care.

Respect and care for a patient should include respect for the cultural group values
involved in their decision-making process. These principles represent the prerequisites for
the conduction of the "Family Meeting" in the ICU that must be recognized as a basic
procedure in critical care. The Family Meeting is a multidisciplinary procedure aimed to
achieve shared choices while allowing humanization of care when dealing with EOL
decisions in the ICU. The practice goals of a Family Meeting have been widely
described29e31 and can be summarised as follows. First of all, physicians have to assess the
family understanding and concerns, sharing information and providing emotional support.
Doing so, it is possible to build trust and to encourage the relatives to use substituted
judgement to establish the goals of care. The Family Meeting may be reactively initiated in
response to specified problems, or it may be proactively established on a routine basis.

Indeed Family Meeting could be elicited by a family crisis, or due to a conflict

concerning the goals of care. After doing so, family and staff need to agree on a care plan and
on the criteria by which the success or failure of the shared care plan would be judged.
Intuitively, a "pre-meeting" staff conference is mandatory in order to clarify the case and to
establish how to conduct the conference. The essential participants to the meeting are the
extended family, although in some cases it is more appropriate to identify a smaller group,
eventually associated with the family doctor, a spiritual advisor and of course an interpreter,
if required.

A conceptual model of the domains of physicians' skill at providing high quality end-
of-life care was described by Curtis et al. First of all, a dyad of cognitive and affective skills
is considered as the basis for an adequate communication with patients/families that focus on
the patients' values in order to construct a patientcentred care system. Despite a growing body
of scientific evidence and clinical experience mandates a specific training on bioethical
aspects of clinical practice in critical care, significant shortcomings in the quality of end of
life care are still observed. Indeed, patients and their families are often not satisfied with the
care received at the end of life in the ICU and communication with caregivers is the least
accomplished factor in quality of care.
 REFERENCES

Consales, G., Zamidei, L., & Michelagnoli, G. (2014). Education and training for moral and
ethical decision-making at the end of life in critical care. Trends in Anaesthesia and
Critical Care, 4(6), 178–181. https://doi.org/10.1016/j.tacc.2014.10.005

Kim, K., Jang, S. G., & Lee, K. S. (2021). A network analysis of research topics and trends in
end-of-life care and nursing. International Journal of Environmental Research and
Public Health, 18(1), 1–15. https://doi.org/10.3390/ijerph18010313