Managing Death in the Intensive Care Unit: The Transition from Cure to Comfort: Edited by J. Randall Curtis and Gordon D. Rubenfeld Published by Oxford University Press, New York, 2001 388 pages, $59.95

Abstract

The intensive care unit (ICU), by reputation, is a place of “high tech” therapies, where patients are likely to receive advanced life support and invasive procedures, no matter the cost in suffering. The intent of critical care has always been to cure illness and prolong life, with the understanding that the burdens of these therapies were justified by the ultimate outcome. In reality, between 10 and 20 percent of ICU patients die, often after long hospital stays, invasive therapies and mechanical life support. Death has traditionally been viewed by intensivists as a failure and the worst possible outcome, but the recent focus on relief of suffering and quality of life has brought the concepts of palliative care to the care of the dying patient in the ICU. The intensivist must now have expertise in both curative and comfort care. Managing Death in the Intensive Care Unit is one of the first books intended for critical care professionals to address this complex topic of death and dying in the ICU, both as clinical and academic disciplines. Aptly subtitled “The Transition from Cure to Comfort” it has several excellent chapters that introduce the concepts, philosophy, and ethical considerations, which are the basis of palliative care in the ICU. The current practice of death management in the ICU has not been well studied, but the authors discuss the available literature and frame crucial questions for future study. In particular, the historical background, landmark cases and ethical framework of patient autonomy, the right to die, and treatment withholding and withdrawal are capably reviewed in the context of ICU practice. Managing end-of-life care in the ICU has several unique and noteworthy aspects. First, the prognosis for ICU patients is often unclear; there is uncertainty as to which patients will die, and what the quality of life may be if they survive. Second, many patients are acutely and severely ill and lack both advance directives and decision-making capacity for their health care. Lastly, almost all patients enter the ICU with intent of receiving aggressive curative therapy and life support. All of these aspects make decision-making around the end of life complex. The book discusses these issues intelligently and in detail in the section entitled, “The Decision to Limit Life Support in the ICU,” clarifying the principles of decision-making in the face of uncertainty. Additional sections on the role of ethnicity and religion, as well as specific disease processes in end-of-life decisions expand upon these themes. There are many clinical and practical skills in the management of death and dying in the ICU. Some of these skills may include communication, conducting a family meeting, breaking bad news, pain management, symptom management and withdrawal of life support, which are discussed and reviewed in Part III of the book. Many of these skills are best practiced by a multidisciplinary team, as is reflected in these chapters, many of which are written by nurses, clergy and non-critical care physicians. The review of the basic principles and pharmacology of opioid pain management is complete for the critical care professional who may not have specific training in pain management principles. While a discussion of the difficult management of pain in the unconscious or critically ill patient would have been helpful in this chapter, it is addressed in the section on critical care nurses and end-of-life care. Unfortunately, some of these areas, such as pain management, warrant an entire book, and alloting only one chapter here does not do the topic justice. Similarly, the management of other important symptoms in the ICU such as dyspnea are only briefly discussed. This unique book is a welcome addition to the critical care literature on the often ignored topic of end-of-life care in the ICU. Drs. Curtis and Rubenfeld should be commended for bringing the concept of the management of death in the ICU forward as a clinical discipline. This book is at its best in the discussion of the ethical and conceptual foundation for end-of-life and palliative care in the ICU. As a practical guide for management it is less useful. I would recommend it highly to all critical care practitioners, both nurses and physicians, as well as medical students, nursing students and residents. Palliative care professionals who consult or interact with intensive care patients will also find it a useful resource for some of the specific issues of end of life in an ICU.