- Book report
Managing death in the intensive care unit: bringing back the humanity
Critical Care volume 6, Article number: 176 (2002)
This new book, edited by Curtis and Rubenfeld, is a very helpful resource for all who work in an intensive care unit (ICU). Although a substantial amount of research has recently explored end of life care in the ICU, few textbooks have included a discussion on how to care for dying patients. This book is the first to fill this glaring void. It combines a comprehensive summary of our current knowledge with guidance on ethical and legal issues, as well some practical suggestions for critical care providers. It reminds us that, although the challenges of caring for the critically ill and the exciting technologies may combine to draw us to the field, the practice of critical care demands that we never forget to use our art to comfort those who will survive and those who will not.
It often remains questionable whether patients and families are truly informed and really appreciate what is involved in life-sustaining therapies. The book provides us with data regarding the current probabilities of survival from a variety of critical illnesses. It also gives practical advice on how to communicate with patients and families, and can serve as a useful reference for clinicians who are engaged in facilitating decision-making for life-sustaining therapies. In the chapter "An international perspective on death in the ICU", Dr Fischer discusses the former Dutch system under which euthanasia was tolerated but still considered illegal. Euthanasia was recently legalized in the Netherlands and while this book likely went to press before the law was adopted, this change will need to be reflected in a new edition.
However, there are two areas that are not explored in great depth. One is that of conflict resolution. Conflicts with families are not uncommon, and even more often conflicts arise within the ICU team or between treating medical and surgical teams. The book accurately describes how other team members such as ethicists can help, but to many clinicians such help is still not available. Clinicians today need to have basic skills in subverting and managing conflict. A helpful resource is the conflict module from the Ian Anderson Continuing Education Program in End of Life Care website http://www.cme.utoronto.ca/endoflife. Another aspect for which only an initial approach is suggested is the effect of culture on end of life care. For more information, interested readers may refer to Braun et al. . Other useful sources are the Canadian Medical Association Journal: Bioethics for Clinicians series (see http://www.cma.ca/cmaj/series/bioethic.htm) [2,3,4,5,6], or the Anderson Program website cited above.
All of us who work in ICUs have had demoralizing weeks during which death seems to be everywhere – weeks with seemingly unending meetings to discuss faint and fading hopes with families and loved ones during which we draw on our own reserves, face our uncertainties and share our own humanity in attempts to support and comfort them. Until recently, we have been expected to cope with such draining tasks on our own and in silence. One of the real strengths of this book is that it breaks this silence and recognizes that we are also people, distinct from our roles as clinicians and certainly distinct from our technologies. In the chapter Making a Personal Relationship with Death, Levy eloquently asks each of us to reflect on our own discomfort with death and how this affects our abilities to care. This chapter and others that discuss finding meaning amidst the technology are a must read for all who practice or who are thinking of embarking on a career in critical care.
In our ongoing search to improve the care we provide to dying patients and their families in the ICU, Curtis and Rubenfeld and all the contributors to this book provide us with some very timely guidance.
Curtis JR, Rubenfeld GD: Managing Death in the ICU: The Transition from Cure to Comfort, Oxford: Oxford University Press, 2001. 388 pp. ISBN 0-19-512881-8.
intensive care unit.
Braun KL, Pietsch JH, Blanchette PL, editors: Cultural Issues in End of Life Decision-Making. Thousand Oaks, CA: Sage Publications, 2000.
Ellerby JH, McKenzie J, McKay S, Gariepy GJ, Kaufert JM: Bioethics for Clinicians 18: Aboriginal Cultures. CMAJ 2000, 163: 845-850.
Conrad H, Sidhu T: Bioethics for Clinicians 19: Hinduism and Sikhism. CMAJ 2000, 163: 1167-1170.
Bowman KW, Hui EC: Bioethics for Clinicians: Chinese Bioethics 20. CMAJ 2000, 163: 1481-1485.
Daar AS, AlKhitamy AB: Bioethics for Clinicians 21: Islamic Bioethics. CMAJ 2001, 164: 60-63.
Goldsand G, Rosenberg ZRS: Bioethics for Clinicians 22: Jewish Bioethics. CMAJ 2001, 164: 219-222.