Heartbeat: Managing end of life patients in critical care

February 9, 2022

By Dr Jon Hulme, Consultant in Anaesthesia and Intensive Care Medicine

There are moments when as clinicians we need to have difficult conversations with our patients and their loved ones about planning for end of life. This can be very challenging for the patient, their family and us as healthcare professionals.

How do we have such conversations when the feeling can often be that our purpose is to do everything we can to save our patients?

As professionals we might be very aware when our treatment plans are simply not working for our patients and however difficult it may be, we need to instigate those conversations early and appropriately. Sometimes, this will be when a patient is able to communicate and understand; other times this will be with someone representing them because they cannot do so themselves. This is usually a close family member.

On intensive care, palliative care most often means stopping treatment that has been keeping a patient alive and making them as comfortable as possible at the end of life. We very much aim that we stop such life sustaining treatment, or do not increase the amount of life support to these levels, with the agreement of the patient and family members.

It becomes complicated when the patient is incapacitated. Very often, the possibility of end of life would have not been discussed prior to the patient getting ill, leaving family members in a difficult position as to what to do. Ultimately it is about explaining to families that life sustaining interventions have failed and they need to prepare for end of their loved one’s life.

Sometimes families will seek a second opinion, which we are happy to accommodate. In very rare occasions we have to seek a judgement from the Court of Protection in cases when the healthcare multidisciplinary team believes that continued life sustaining treatment is not in the best interests of the patient. Thankfully, this is an extremely rare occurrence.

Such conversations, explaining and discussing treatment escalation plans and end of life considerations, have been made even more difficult during the pandemic when we have to had to speak to family members on the phone or a video call – naturally we would prefer to do this face to face.

When end of life is planned well, it is a more dignified process for the patient. We (including the patient and family) are able to plan for the event and ensure the patient is as comfortable as they can be. Sometimes, they are able to be discharged home or move to a hospice from critical care if that is their wish.

Planning end of life is not easy. Everyone involved in the patient’s journey needs to have these conversations including the GP, admitting teams and those providing longer term care in hospital. Ultimately, it is about talking with people on a human level and understanding what their understanding, expectation and wishes are. When we take time to ask, we may be very surprised at how different this is from what we think is best for the patient.

Training for medics to have these conversations is now much improved. Trainee doctors are now trained and assessed by taking part in various scenarios. But for those of us who qualified years ago, this is did not happen. Many have learnt by experience and, just like after passing your driving test, bad habits and techniques can creep in. Even for those who do it well and frequently, some situations can be still very challenging.

If I had a piece of advice to give, I would encourage you to talk to your patient about what they want. And ask them, don’t tell them.

Ask yourself: is there a point when life would become unacceptable because you cannot do those things you hold most dear to you? And that is the core of what we ought to know about our patients’ wishes.