Death is common in the intensive care unit (ICU), with approximately 20% of deaths in the United States occurring during or shortly after a stay in an ICU.1 The majority of these deaths involve the withholding or withdrawal of life-sustaining therapy.2 Therefore, the ICU represents a particularly distinct clinical setting where the thoughtful and considered application of ethical concepts is required. A proper understanding of the basic principles of bioethics as well as the principles of providing comfort-focused, end-of-life care are essential elements in the competent practice of intensive care medicine.
A number of common ethical themes arise in the ICU. Technological advancements have allowed healthcare providers to keep patients alive for prolonged periods in the context of diseases that, in the past, would have resulted in death. However, the capacity for delivering life-sustaining care has not been matched by efforts to align treatments with the care individual patients wish to receive at end of life, resulting in a discordance between care wanted and care received.3–5 Compounding this problem is the reality that many patients dying in the ICU, prior to death, lack the capacity to make decisions regarding end-of-life care6 and have not completed an advance directive that might aid surrogates and physicians in the decision-making process.7 Many decisions about end-of-life care in the ICU are, therefore, made without the involvement or input of the patient.6 The resulting uncertainty means that many patients frequently receive far more aggressive interventions than they would have otherwise chosen for themselves, or they receive care that has a low likelihood of restoring health, enabling discharge from the ICU, and having the potential for providing a meaningful quality of life.5
Ethical dilemmas that characterize critical care medicine often arise from this interface between the ability to prolong life by expensive and sometimes scarce technology and an inability to cure patients or restore them to their baseline. The relevant ethical question often is whether technology is being used wisely, that is, should the patient's life be prolonged? The question becomes even more complex for practitioners and patients’ families when different ethical principles suggest conflicting answers.
Although the practice of critical care medicine encompasses a broad range of bioethical issues, several are particularly common, including palliative and end-of-life care, surrogate decision making, medical futility, communication, and professionalism. These issues are among the most challenging for critical care practitioners and constitute the focus of this chapter.
Fundamental Principles of Bioethics
Several fundamental principles of bioethics are at the core of the practice of critical care medicine: respect for patient autonomy, beneficence, nonmaleficence, and distributive justice.8 Ethical dilemmas in the ICU arise when two or more of the principles are in conflict. An understanding of these areas provides a basis for addressing conflict and is imperative in providing high-quality palliative care at the end-of-life.