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The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research., (© 2024. The Author(s).)

Background: Critical care and palliative care professionals treat and support seriously ill patients on a daily basis, and the possibility of burnout may be high. The consequences of burnout can include moral injury and distress, and compassion fatigue, which are detrimental to both care and staff., Aims and Objectives: To explore the incidence of moral distress in areas at high risk of burnout in a large cancer centre and to explore possible measures for addressing moral distress., Design: A cross-sectional survey., Methods: The Maslach Burnout Inventory was administered to critical care, critical care outreach, and palliative care teams in a specialist tertiary cancer centre. Open questions on supportive measures were also included. Burnout data were categorised into three domains of emotional exhaustion, depersonalization and personal accomplishment, and free-text analysis was conducted on the open-question data., Results: A total of 63 professionals responded across the teams (45% response rate). A low level of burnout was observed in the emotional exhaustion domain; depersonalization was higher in the critical care professionals; and overall, personal accomplishment was higher than normative scores. Free-text analysis highlighted three categories of responses: Debriefing, Managing emotional well-being, and Valuing individuals. There was a need to proactively recognize issues; undertake more debriefs; and open forums regarding cases, particularly with difficult deaths. Engaging all professionals, support to deal with families, and mandatory moral distress and resilience training were suggested, alongside a focus on team building through external activities such as group relaxation sessions and walks., Conclusions: This study demonstrated a relatively low incidence of emotional exhaustion and depersonalization, and a slightly higher sense of personal accomplishment than normative scores despite staff working in an environment where high levels of burnout were expected., Relevance to Clinical Practice: Staff highlighted possible solutions to reduce burnout, which included debriefing, managing emotional well-being, and valuing individuals., (© 2019 British Association of Critical Care Nurses.)

Rapid response teams, such as critical care outreach teams, have prominent roles in managing end-of-life transitions in critical illness, often questioning appropriateness of treatment escalation. Clinical uncertainty presents clinicians with dilemmas in how and when to escalate or de-escalate treatment., Aims and Objectives: To explore how critical care outreach team decision-making processes affect the management of transition points for critically ill, ward-based patients with a life-limiting illness., Methods: An ethnographic study across two hospitals observed transition points and decisions to de-escalate treatment, through the lens of critical care outreach. In-depth interviews were carried out to elucidate rationales for practices witnessed in observations. Detailed field notes were taken and placed in a descriptive account. Ethnographic data were analysed, categorised and organised into themes using thematic analysis., Findings: Data were collected over 74 weeks, encompassing 32 observation periods with 20 staff, totalling more than 150 hr. Ten formal staff interviews and 20 informal staff interviews were undertaken. Three main themes emerged: early decision-making and the role of critical care outreach; communicating end-of-life transitions; end-of-life care and the input of critical care outreach. Findings suggest there is a negotiation to achieve smooth transitions for individual patients, between critical care outreach, and parent or ward medical teams. This process of negotiation is subject to many factors that either hinder or facilitate timely transitions., Conclusions: Critical care outreach teams have an important role in shared decision-making. Associated emotional costs relate to conflict with parent medical teams, and working as lone practitioners. The cultural contexts in which teams work have a significant effect on their interactions and agency., Relevance to Practice: There needs to be a cultural shift towards early and open discussion of treatment goals and limitations of medical treatment, particularly when facing serious illness. With training and competencies, outreach nurses are well placed to facilitate these discussions., (© 2018 Crown copyright. Journal of Clinical Nursing © 2018 John Wiley & Sons Ltd.)

Objectives: Most people when asked, express a preference to die at home, but little is known about whether this is an option for critically ill patients. A retrospective cohort study was undertaken to describe the size and characteristics of the critical care population who could potentially be transferred home to die if they expressed such a wish., Methods: Medical notes of all patients who died in, or within 5 days of discharge from seven critical care units across two hospital sites over a 12-month period were reviewed. Inclusion/exclusion criteria were developed and applied to identify the number of patients who had potential to be transferred home to die and demographic and clinical data (eg, conscious state, respiratory and cardiac support therapies) collected., Results: 7844 patients were admitted over a 12-month period. 422 (5.4%) patients died. Using the criteria developed 100 (23.7%) patients could have potentially been transferred home to die. Of these 41 (41%) patients were diagnosed with respiratory disease. 53 (53%) patients were conscious, 47 (47%) patients were self-ventilating breathing room air/oxygen via a mask. 20 (20%) patients were ventilated via an endotracheal tube. 76 (76%) patients were not requiring inotropes/vasopressors. Mean time between discussion about treatment withdrawal and time of death was 36.4 h (SD=46.48). No patients in this cohort were transferred home., Conclusions: A little over 20% of patients dying in critical care demonstrate potential to be transferred home to die. Staff should actively consider the practice of transferring home as an option for care at end of life for these patients., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Little research has examined the involvement of critical care outreach teams in end-of-life decision making., Objective: To establish how much time critical care outreach teams spend with patients who are subsequently subject to limitation of medical treatment and end-of-life decisions and how much influence the teams have on those decisions., Methods: A single-center retrospective review, with qualitative analysis, in a large cancer center. Data from all patients referred emergently for critical care outreach from October 2010 to October 2011 who later had limitation of medical treatment or end-of-life care were retrieved. Findings were analyzed by using SPSS 19 and qualitative free-text analysis., Results: Of 890 patients referred for critical care outreach from October 2010 to October 2011, 377 were referred as an emergency; 108 of those had limitation of medical treatment and were included in the review. Thirty-five patients (32.4%) died while hospitalized. As a result of outreach intervention and a decision to limit medical treatment, 56 (51.9%) of the 108 patients received a formal end-of-life care plan (including care pathways, referral to palliative care team, hospice). About a fifth (21.5%) of clinical contact time is being spent on patients who subsequently are subject to limitation of medical treatment. Qualitative document analysis showed 5 emerging themes: difficulty of discussions about not attempting cardiopulmonary resuscitation, complexities in coordinating multiple teams, delays in referral and decision making, decision reversals and opaque decision making, and technical versus ethical imperatives., Conclusion: A considerable amount of time is being spent on these emergency referrals, and decisions to limit medical treatment are common. The appropriateness of escalation of levels of care is often not questioned until patients become critically or acutely unwell, and outreach teams subsequently intervene., (©2015 American Association of Critical-Care Nurses.)

Aims and Objectives: To explore the meaning of end-of-life care for critically ill cancer patients, families, oncologists, palliative care specialists, critical care consultants and nurses., Background: End-of-life care for critically ill patients, of whom nearly 20% will die in critical care, remains somewhat problematic (Truog et al. 2008). End-of-life care is an established domain in cancer; however, research has not been conducted previously into dying, critically ill cancer patients' experiences., Design: Qualitative, phenomenological in-depth interviews were undertaken., Methods: Phenomenology was used to explore experiences of 27 participants: surviving patients at high risk of dying, bereaved families, oncologists, palliative and critical care consultants, and nurses. Purposive sampling from a UK critical care unit was carried out. In-depth interviews were taped analysed using Van Manen's phenomenological analysis framework., Results: A phenomenological interpretation of dying in cancer critical illness, and the impact on opportunities for end-of-life care, is presented. Three main themes included: dual prognostication; the meaning of decision-making; and care practices at end of life: choreographing a good death. End-of-life care was an emotive experience for all participants; core tenets for good end-of-life care included comfort, less visible technology, privacy and dignity. These findings are discussed in relation to end-of-life care, cancer and critical illness., Conclusion: The speed of progressing towards dying in critical illness is often unknown and subsequently affects potential for end-of-life care. Caring was not unique to nurses and end-of-life care in critical care came with considerable emotional cost., Relevance to Clinical Practice: There is an opportunity for nurses to use the care of patients dying in critical care to develop specialist knowledge and lead in care, but it requires mastery and reconciliation of both technology and end-of-life care. Healthcare professionals can help facilitate acceptance for families and patients, particularly regarding involvement in decisions and ensuring patient advocacy., (© 2013 Blackwell Publishing Ltd.)

This article outlines the steps involved in preparing the patient after death--known as last offices. It addresses legal and non-legal issues, religious considerations, hygiene care and aftercare for the family.

Unlabelled: This article highlights certain practical and professional difficulties in providing end-of-life (EOL) care for patients in critical care units and explores discourses arising from guidelines for critical care services., Background: A significant number of patients die in critical care after decisions to withdraw or withhold treatment. Guidelines for provision of critical care suggest, wherever possible, moving patients out of critical care at the EOL. This may not necessarily be conducive to a 'good death' for patients or their loved ones. There is a moral responsibility for both nurses and doctors to ensure that decision-making around EOL issues is sensitively implemented, that decisions about care includes families, patients when able, nurses and doctors, and that good EOL care is provided., Methods: A critical discourse analysis (CDA) of four key UK critical care documents published since 1996., Findings and Recommendations: The key documents give little clear guidance about how to provide EOL care in critical care. Discourses include the power dynamic in critical care between professions, families and patients, and how this impacts on provision of EOL care. Difficulties encountered include dilemmas at discharge and paternalism in decision-making. The technological environment can act as a barrier to good EOL care, and critical care nurses are at risk of assuming the dominant medical model of care. Nurses, however, are in a prime position to ensure that decision-making is an inclusive process, patient needs are paramount, the practical aspects of withdrawal lead to a smooth transition in goals of care and that comfort measures are implemented.

End-of-life care in the critical care environment suffers from a lack of clarity and uncertainty. Critical care nurses may often feel torn between wanting to do everything possible to sustain a patient's life and wanting to do what is in the patient's best interests. Reframing the focus of care from cure to comfort can be an uncomfortable shift for nurses, who may not be in control of when the change of goals takes place. Good end-of-life care should be a core competency for all nurses and it is our responsibility to ensure that decisions to forgo life-sustaining treatment in critical care are appropriate and timely. Futility, conflict and resources all factor in such decisions. Nurses must ensure the transition from cure to comfort does not emphasize a dichotomy between palliative care and critical care but instead focuses on the provision of the best possible end-of-life care.