Improving care at end of life in the ICU: A proposal for early discussion of goals of care

摘要

Improving care at end of life (EOL) in the intensive care unit (ICU) remains a challenge, especially for older adults, who face a high likelihood of mortality or profound functional impairment with admission to the ICU and use of life-sustaining treatment (LST) such as mechanical ventilation. Multiple factors pose a barrier to high-quality EOL care that is consistent with patient preferences and values. This article outlines key contributory factors to this problem and offers, as a solution, a proposal for earlier engagement with decisional surrogates to clearly define the surrogate role; outline the risks, benefits, and alternatives to LSTs in use; and clarify patient-specific goals of care. Nurses should play a pivotal role in the development of programs to implement early discussion of goals of care, and they are instrumental in identifying patients at risk and facilitating early engagement with surrogates in facilities where such programs exist. Research that systematically evaluates outcomes of such protocols is needed to guide policy for patient-centered EOL care in the ICU.