Incorporating palliative care into critical care education: Principles, challenges, and opportunities

Objective: To identify the goals and methods for medical education about end-of-life care in the intensive care unit (ICU). Data Sources and Study Selection: A status report on palliative care, a summary report of recent research on palliative care education, articles in the medical literature on end-of-life care and critical care, and expert opinion were considered. Data Extraction: A working group, including specialists in critical care, palliative care, medical ethics, consumer advocacy, and communications, was convened at the 'Medical Education for Care Near the End of Life National Consensus Conference.' A modified nominal group process was used to develop a consensus. Data Synthesis: In the ICU, life and death decisions are often made in a crisis mode or in the face of uncertainty, and may necessitate the withholding and withdrawal of life-supporting technologies. Because critical illness often diminishes the capacity of patients to make decisions, clinicians must often make decisions in conjunction with surrogates, rather than with patients. Discontinuity of care can threaten trusting relationships, and cultural diversity can have a particularly powerful impact on choices for care. In the face of these realities, it is possible and appropriate to give compassionate palliative care to dying patients and their families in the ICU. Conclusions: Teaching care of the dying in the ICU should emphasize the following: a) the goals of care should guide the use of technology; b) understanding of prognostication and treatment withholding and withdrawal is essential; c) effective communication and trusting relationships are crucial to good care; d) cultural differences should be acknowledged and respected; and e) the delivery of excellent palliative care is appropriate and necessary when patients die in the ICU.