Ethics
Should Emergency Department Patients with End-of-Life Directives be Admitted to the ICU?

https://doi.org/10.1016/j.jemermed.2018.06.009Get rights and content

Abstract

Background

Whether emergency physicians should utilize critical care resources for patients with advance care planning directives is a complex question. Because the cost of intensive care unit (ICU)-level care, in terms of human suffering and financial burden, can be considerable, ICU-level care ought to be provided only to those patients who would consent and who would benefit from it.

Objectives

In this article, we discuss the interplay between clinical indications, patient preferences, and advance care directives, and make recommendations about what the emergency physician must consider when deciding whether a patient with an advance care planning document should be admitted to the ICU.

Discussion

Although some patients may wish to avoid certain aggressive or invasive measures available in an ICU, there may be a tendency, reinforced by recent Society of Critical Care Medicine guidelines, to presume that such patients will not benefit as much as other patients from the specialized care of the ICU. The ICU still may be the most appropriate setting for hospitalization to access care outside of the limitations set forward in those end-of-life care directives. On the other hand, ICU beds are a scarce and expensive resource that may offer aggressive treatments that can inflict suffering onto patients unlikely to benefit from them. Goals-of-care discussions are critical to align patient end-of-life care preferences with hospital resources, and therefore, the appropriateness of ICU disposition.

Conclusions

End-of-life care directives should not automatically exclude patients from the ICU. Rather, ICU admission should be based upon the alignment of uniquely beneficial treatment offered by the ICU and patients’ values and stated goals of care.

Section snippets

Case 1

A 75-year-old woman with a history of severe chronic obstructive pulmonary disease presents to a community emergency department (ED) with fever, respiratory distress, and altered mental status. She is found to have pneumonia, and after antibiotics, glucocorticoids, beta agonists, and a period of time on noninvasive positive-pressure ventilation (NIPPV), begins to improve. However, she is still requiring venturi mask at 40% O2 to maintain saturations of 93%, and has an elevated respiratory rate.

Arguments Against the Exclusion of Patients from the ICU Based upon Having an EOL Care Document

For patients with advance planning/EOL care documents that express a desire not to receive aggressive interventions such as pressors or intubation, the ICU might still be an appropriate setting for hospitalization. ICU nurses and critical care physicians/intensivists might be more comfortable with, and skilled in, providing necessary doses of opioids and benzodiazepines, as well as other medications such as glycopyrrolate used in palliative care settings. The ICU also offers respiratory care

Conclusion

End-of-life care documents should not automatically exclude patients from the ICU. The key question for the emergency physician is, “Can the ICU offer uniquely beneficial treatment that would also align with the patient's values and stated goals of care?” End-of-life care documents are but one tool to help physicians understand patients' goals and wishes regarding specific life-sustaining interventions. Real-time conversations with patients or surrogates about goals of care in light of the

References (30)

  • S.M. Dunlay et al.

    Advance directives in community patients with heart failure

    Circ Cardiovasc Qual Outcomes

    (2012)
  • J.M. Teno et al.

    Association between advance directives and quality of end-of-life care: a national study

    J Am Geriatr Soc

    (2007)
  • M. Garrouste-Orgeas et al.

    The ETHICA study (part II): simulation study of determinants and variability of ICU physician decisions in patients aged 80 or over

    Intensive Care Med

    (2013)
  • N.A. Halpern

    Can the costs of critical care be controlled?

    Curr Opin Crit Care

    (2009)
  • S. Frick et al.

    Medical futility: predicting outcome of intensive care unit patients by nurses and doctors–a prospective comparative study

    Crit Care Med

    (2003)
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