Palliative Care in the ICU and the Role for Physician-Assisted Dying—Or Lack Thereof*

    loading  Checking for direct PDF access through Ovid


The prevalence of critical illness in the United States has dramatically increased, primarily as the result of an aging population and advances in the effectiveness and availability of critical care (1, 2). Approximately 20% of deaths in the United States occur in the ICU, a higher proportion than other developed nations (3, 4). The vast majority of these deaths are preceded by a decision to withhold or withdraw life-sustaining treatments, attesting to the fact that critical care clinicians are frequently involved in working with patients or, more commonly, family members to make difficult decisions about when the burdens of continuing life support—and life itself—may outweigh the benefits (5). In this context, it is easy to see why the issue of physician-assisted dying (PAD) might seem relevant in the ICU. In this issue of Critical Care Medicine, Goligher et al (6) provide a well-constructed overview and respectful debate about the issues of physician-assisted suicide and voluntary euthanasia, for which we will use the term “PAD.” Although we congratulate the authors on this thoughtful article, we argue that PAD is rarely, if ever, relevant in the ICU and that ICU clinicians should instead focus their efforts on ensuring shared decision making with the incorporation of the patient’s goals of care and other components of palliative care for dying patients rather than any consideration of PAD.
Although ICU clinicians have been at the forefront of the debate around the ethical issues of end-of-life care, we will necessarily take a back seat in any move toward PAD. In the United States, all existing PAD laws require that patients with decisional capacity be able to request PAD and that this request be consistent over time (7). Ethically, any consideration of honoring a patient’s request to shorten his or her life is predicated on the notion that the request represents a truly autonomous choice. Yet, critically ill patients, even those few who may meet criteria for basic decision-making capacity, will necessarily have compromised autonomy (8). We believe that there is no jurisdiction in North America nor compelling ethical argument that allows for surrogate decision makers to chose PAD for another individual, meaning that PAD has no place in ICUs. PAD should be an outpatient intervention. In the over 400 reported deaths occurring with physician assistance in the State of Washington between 2009 and 2014, only one occurred in a hospital (9). In the context of ICU care for critically ill patients, the option of withdrawing life-sustaining treatments and—if needed—offering palliative sedation renders PAD unnecessary to provide a comfortable and dignified death.
High-quality critical care must incorporate high-quality palliative care—care that focuses on ensuring that we assess and address patients’ symptoms, incorporate considerations of quality of life, explore the values and goals of patients, incorporate these values and goals into our clinical decision making, and address the needs and concerns of the patient’s family and loved ones (10, 11). Palliative care in the ICU should include both primary palliative care (palliative care provided by the ICU clinicians) and specialty palliative care (additional support provided by palliative care specialists and others) in an integrated and coordinated manner (12). Unfortunately, there is ample evidence that many critically ill patients have poorly controlled symptoms (13, 14), that patients’ goals of care are frequently not addressed (15), and that decision making during ICU family conferences frequently misses many key components of high-quality shared decision making (16). Consideration of PAD to address suffering prior to the implementation of high-quality palliative care is both poor quality care and unethical.
    loading  Loading Related Articles

Join Ovid Insights!

Benefits of Ovid Insights Include:

  • Consolidated email digests of the latest research in your favorite topics
  • A personalized dashboard of your topics all on one page 
  • Tools to bookmark and share articles of interest
  • Ability to customize and save your own searches

Register with Ovid Insights »