Correspondence
Communicating about Dying in the ICU
N Engl J Med 2007; 356:2003-2005May 10, 2007
- Article
To the Editor:
The report by Lautrette and colleagues on a communication strategy for physicians to use with relatives of patients dying in the intensive care unit (ICU) (Feb. 1 issue)1 reminds me of a smile flashed by a critical care specialist at the climax of a walk through a new ICU at a private hospital in the United States. My tour guide was particularly proud of the back door through which she escaped time-consuming encounters with families who routinely occupied waiting rooms near the front door.
Will more than scientific evidence of a benefit be needed before most physicians linger and listen to their patients' loved ones in ICUs? In the United States, we need to modify the way physicians are paid in order to facilitate family meetings in the ICU and reward physicians in proportion to the required skill, extraordinary intensity, and irregular hours associated with this vital service. We also need to draw into critical care medicine more practitioners who are equally adept at preventive, restorative, and palliative care.
1 ReferencesJohn Hansen-Flaschen, M.D.
University of Pennsylvania, Philadelphia, PA 19104
jflash@uphs.upenn. edu 1
Lautrette A ,Darmon M ,Megarbane B , et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469-478
Full Text | Web of Science | Medline
To the Editor:
An increasing number of patients are dying in ICUs at tremendous emotional and financial cost.1 Even in the study by Lautrette et al., in which the criterion for inclusion was the belief that the patients were near death and there was a decision to forgo life-sustaining treatment, for most patients life-sustaining procedures were not withdrawn (Fig. 1 in the Supplementary Appendix of the report). Once a decision is made that the technological and procedural armamentarium of the ICU will no longer be of benefit to the patient, end-of-life treatment should be referred to palliative care experts, and if hospice facilities are not practical, the patient should be cared for in a regular hospital bed. End-of-life care in a regular hospital bed, as compared with a bed in an ICU, conserves significant resources and allows for better palliation and family support.2 We are facing a crisis in the financing of our health care system, and inappropriate end-of-life care in the ICU contributes to this problem.3
3 ReferencesKenneth A. Fisher, M.D.
4335 Roxbury Lane, Kalamazoo, MI 49008
momfish1@charter.net 1
Barnato AE ,McClellen MB ,Kagay CR ,Garber AM . Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life. Health Serv Res 2004;39:363-375
CrossRef | Web of Science | Medline2
Rady MY ,Johnson D . Admission to intensive care unit at the end-of-life: is it an informed decision? Palliat Med 2004;18:705-711
CrossRef | Web of Science | Medline3
Angus DC ,Barnato AE ,Linde-Zwirbl WT , et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med 2004;32:638-643
CrossRef | Web of Science | Medline
To the Editor:
There is a need to develop a process for evaluating and improving end-of-life conferences in ICUs. However, if an end-of-life intervention is performed and the patient survives, what will be the effect of the communication strategy, especially if decisions such as that to discontinue or forgo advanced life support were made?1,2 In addition, we wonder whether any analysis of the social, educational, and economic status of the families who actually read the bereavement brochure was performed, and whether these factors might have influenced the outcome measures.
2 ReferencesDimitrios Karakitsos, M.D., Ph.D.
Andreas Karabinis, M.D., Ph.D.
General State Hospital of Athens, 11354 Athens, Greece
echolabicu@gmail.com 1
Cook D ,Rocker G ,Marshall J , et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 2003;349:1123-1132
Full Text | Web of Science | Medline2
Sprung CL ,Cohen SL ,Sjokvist P , et al. End-of-life practices in European intensive care units: the Ethicus Study. JAMA 2003;290:790-797
CrossRef | Web of Science | Medline
Author/Editor Response
Hansen-Flaschen raises the question of charging professional fees for family counseling. Since our study was performed in France, where all hospital physicians are paid a salary, the critical care clinicians were not paid specifically for the time they spent with the family; counseling is considered part of the physicians' job description. We agree fully that the doors of the ICU should be open to palliative care clinicians. However, these clinicians will also need to be paid, and there will have to be a sufficient number of them to ensure availability at all times; in addition, they will have to evaluate the efficiency of their interventions. Until these conditions are met, the proactive strategy evaluated in our study provides ICU physicians with a tool for better meeting the specific needs of relatives of dying patients.
As Fisher points out, lifesaving therapies were not withdrawn from most of the patients in our study, since in France, dying patients are not usually discharged from the ICU to the wards. We realize that there is substantial variation in discharge practices for dying patients across countries and cultures.1,2 Although we agree that discharge from the ICU may be appropriate for a dying patient if the destination ward is equipped to provide both the patient and the relatives with appropriate care and support, it is not clear whether such a strategy saves money.3 We remain reluctant to transfer a dying patient to a ward, unless the patient was in that ward before admission to the ICU and will be returned to the care of a team that knows him or her.
We agree with Karakitsos and Karabinis that having information on families' perception of the brochure, in general and for specific subgroups, would be of interest. In our study, the controlled design of the intervention did not permit the interviewer to ask study participants whether they read the brochure and how they perceived the information in it. It would be of value to understand through interviews the specific ways in which the communication strategy and the brochure helped the family.
3 ReferencesElie Azoulay, M.D., Ph.D.
Alexandre Lautrette, M.D.
Benoit Schlemmer, M.D.
Saint-Louis Hospital, 75010 Paris, France
elie.azoulay@sls. aphp. fr 1
Sprung CL ,Cohen SL ,Sjokvist P , et al. End-of-life practices in European intensive care units: the Ethicus Study. JAMA 2003;290:790-797
CrossRef | Web of Science | Medline2
Mebane EW ,Oman RF ,Kroonen LT ,Goldstein MK . The influence of physician race, age, and gender on physician attitudes toward advance care directives and preferences for end-of-life decision-making. J Am Geriatr Soc 1999;47:579-591
Web of Science | Medline3
Luce JM ,Rubenfeld GD . Can health care costs be reduced by limiting intensive care at the end of life? Am J Respir Crit Care Med 2002;165:750-754
Web of Science | Medline
