Managing Death in the Intensive Care Unit: The Transition from Cure to Comfort
For those who care for patients in the intensive care unit (ICU), dealing with the complex medical and psychosocial issues surrounding death and the dying patient is a daily event. However, the necessary practical skills are rarely learned as part of formal training, and many of us approach these issues awkwardly and with some discomfort. The editors of Managing Death in the Intensive Care Unit have set a formidable goal: to create a book that reviews the topic of death and dying in the ICU in a scholarly way and provides specific, practical advice for caring for critically ill and dying patients. As stated in the introduction, the overall objective of the book is to improve the care of patients dying in the ICU, a goal that will be achieved, in part, the editors say, ``when the book is found, dog-eared and scribbled on, at ICU nurses' stations and physicians' workrooms.''The book is a compilation of chapters by experts in the field, including critical care physicians, nurse specialists, psychologists, ethicists, and pastoral care providers. Separate sections focus on the changing landscape of death in the ICU, the decision to limit life support, the practical skills needed to manage death, societal issues, and specific diseases and special populations, including the elderly, infants, and children. The chapters cover a remarkable variety of topics, both theoretical and practical, ranging from basic ethics and the economics of death in the ICU to pain management and legal issues. The multidisciplinary approach is one of the strengths of the book; the different perspectives of the authors and the variety of topics covered give the reader a multidimensional appreciation of the issues surrounding death and dying in the ICU that would have had less of an impact if, for instance, the contributors were solely physicians.Although the chapter on ethics is more historical than practical, the book provides an excellent overview of the various ethical issues of end-of-life care in the ICU. The section on making the decision to limit life support deals thoroughly with this subject, and a variety of important ideas are presented. For example, the reader is reminded that ``correct'' decision making is an untenable construct. Adaptive behavior patterns that are not necessarily logical or ethically sound are also identified. ``A preference for maintaining the status quo'' rather than withdrawing futile treatments is identified as an adaptive tendency of families and clinicians -- one that will be familiar to many readers. Although it is brief, the chapter on economics is thought provoking and highlights the lack of tools for assessing the economic impact of improvements in end-of-life care.Readers who are involved in the care of critically ill patients will find the section on the skills needed to manage death in the ICU to be the most useful. The section is practical, with basic advice for discussions with families, the withdrawal of support, and pain management. Although one might assume that such skills cannot be effectively learned from a book, these chapters provide practical pointers, often in tabular form, that can be incorporated easily and effectively into interactions with patients, their families, and the critical care team. Indeed, it is clear that the authors have extensive experience in teaching these skills. For the clinician-educator, the chapters in this section could easily stand alone as launching points for teaching sessions on critical care.The editors succeed in their goal, but the book does have a few weaknesses. Because of the wide variety of topics, many subjects are not covered in great depth, and readers may wish to turn to other sources cited in the book. Some of the chapters contain redundant information, a problem that is most apparent when the book is read from cover to cover but that would be less problematic if it were used as a topical reference. Finally, despite the editors' attempts to organize the book into related sections, the chapters do not always interrelate well.Managing Death in the Intensive Care Unit reminds us that the provision of excellent palliative care to the dying patient is a worthy and attainable goal. Indeed, the skills that the book strives to teach are as useful and important as learning how to manage mechanical ventilation or septic shock. The book will be a valuable reference for anyone who cares for critically ill patients, including physicians, nurses, respiratory therapists, pastoral care providers, and students, and would be a useful addition to any ICU reference library. I, too, am hopeful that this book will be found, dog-eared and scribbled on, in many critical care units.Lorraine B. Ware, M.D.Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.