Dying with Dignity in the Intensive Care Unit

THE TRADITIONAL GOALS OF INTENSIVE CARE ARE TO REDUCE THE -morbidity and mortality associated with critical illness, maintain organ function, and restore health. Despite technological advances, death in the intensive care unit (ICU) remains commonplace. Death rates vary widely within and among countries and are influenced by many factors.(1) Comparative international data are lacking, but an estimated one in five deaths in the United States occurs in a critical care bed.(2) In this review, we address the concept of dignity for patients dying in the ICU. When the organ dysfunction of critical illness defies treatment, when the goals of care can no longer be met, or when life support is likely to result in outcomes that are incongruent with patients' values, ICU clinicians must ensure that patients die with dignity. The definition of "dying with dignity" recognizes the intrinsic, unconditional quality of human worth but also external qualities of physical comfort, autonomy, meaningfulness, preparedness, and interpersonal connection.(3) Respect should be fostered by being mindful of the "ABCDs" of dignity-conserving care (attitudes, behaviors, compassion, and dialogue)(4) (Table 1). Preserving the dignity of patients, avoiding harm, and preventing or resolving conflict are conditions of the privilege and responsibility of caring for patients at the end of life. In our discussion of principles, evidence, and practices, we assume that there are no extant conflicts between the ICU team and the patient's family. Given the scope of this review, readers are referred elsewhere for guidance on conflict prevention and resolution in the ICU.(5,6) The concept of dying with dignity in the ICU implies that although clinicians may forgo some treatments, care can be enhanced as death approaches. Fundamental to maintaining dignity is the need to understand a patient's unique perspectives on what gives life meaning in a setting replete with depersonalizing devices. The goal is caring for patients in a manner that is consistent with their values at a time of incomparable vulnerability, when they rarely can speak for themselves. 7 For example, patients who value meaningful relationships may decline life-prolonging measures when such relationships are no longer possible. Conversely, patients for whom physical autonomy is not crucial may accept technological dependence if it confers a reasonable chance of an acceptable, albeit impaired, outcome. 8 At issue is what each patient would be willing to undergo for a given probability of survival and anticipated quality of life.