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Intensive Caring at the End of Life

Thomas J. Prendergast, MD; Kathleen A. Puntillo, RN, DNSc

JAMA. 2002;288:2732-2740.

The technology and expertise of critical care practice support patients through life-threatening illnesses. Most recover; some die quickly; others, however, linger—neither improving nor acutely dying, alive but with a dwindling capacity to recover from their injury or illness. Management of these patients is often dominated by the question: Is it appropriate to continue life-sustaining therapy? Patients rarely participate in these pivotal discussions because they are either too sick or too heavily sedated. As a result, the decision often falls to the family or the surrogate decision maker, in consultation with the medical team. Decisions of such import are emotionally stressful and are often a source of disagreement. Failure to resolve such disagreements may create conflict that compromises patient care, engenders guilt among family members, and creates dissatisfaction for health care professionals. However, the potential for strained communications is mitigated if clinicians provide timely clinical and prognostic information and support the patient and family with aggressive symptom control, a comfortable setting, and continuous psychosocial support. Effective communication includes sharing the burden of decision making with family members. This shift from individual responsibility to patient-focused consensus often permits the family to understand, perhaps reluctantly and with great sadness, that intensive caring may involve letting go of life-sustaining interventions.

Author Affiliations: Departments of Medicine and Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Dr Prendergast); Department of Physiological Nursing, School of Nursing, University of California, San Francisco (Dr Puntillo).

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