Juan Francisco Velarde García
Profesor de la Escuela Universitaria de Enfermería Cruz Roja. Madrid.
Contact email: JVG@cruzroja.es
Versión en Español
Different international studies have pointed out that between 16 and 19% of hospital deaths take place at Critical Care Units (CCUs) (1). It is estimated that more than 50% of deaths occur after some type of limitation of therapeutic effort (2,3).
The need to provide care to patients in non-reversible clinical situations has become increasingly frequent; this is associated with advanced age, the presence of underlying chronic diseases, and the change in threatening situations. It must be remembered that CCUs were created with the sole end to ensure patient cure, and they represent the flagship of healthcare “technification”. However, there is a progressive increase in the number of critical patients in teminal situation, and we use technology as a shield not only to protect the lives of patients, but also to face their death, often denying their irreversible clinical situation, and being unable to acknowledge that life has its own limits, and nothing can be done to change the situation.
Regardless of the increasing initiatives towards humanizing critical care, the influence of the biomedical model on healthcare culture, the training of professionals and the resources used have not allowed to change the term “limitation of therapeutic effort” by “palliative care of the critical patient in terminal situation”, with everything this involves and entails. In this case, some questions can be considered: Are there different needs for patients in terminal situation and their families within this setting? Why not speak openly of palliative care or end-of-life care, instead of using the term “limtation if thepeutic effort”? Is this a matter of terminology only, or does it go beyond this? Providing end-of-life care involves the need to face the death of the patient, which is not easy within these care settings. The way and time in which the death of the patient presents to us, added to any personal involvement developed with them and / or their family, will probably be decisive in its acceptance. The unexpected death of a patient is not only unpredictable and unacceptable for their relatives and close friends, but also for ourselves, because death does not always occur in those persons for whom it would be more predictable and therefore easier to accept by those professionals involved in their care. Some other times, the time of patient death has a clear connotation of justice: we differentiate between the death of a young patient and that of an elderly person. The latter can be accepted quite naturally within the cycle of life, while the death of a young patient is perceived with a feeling of injustice.
Finally, personal involvement with our patients leads to professional and personal aspects frequently intermingling, depending on the relationship established with the patient and his/her family, which might even affect us emotionally. There is a higher presence of difficulties than would be desirable at the time of providing good quality care at the end of the life of these patients, given the low training received by many professionals on this matter, the lack of protocols or care plans including the needs of this type of patients and their relatives, and even the lack of skills by professionals in order to face these situations. Moreover, the structural design of CCUs does not offer the privacy needed by patients and relatives at the time of mourning.
As a conclusion, we must not forget that our privileged position as nursing professionals allows us to share with patients and relatives such a significant moment as the end of life. Maybe we are not in the best place to offer comprehensive care, but needs are still present, and it is our responsibility to make an effort in order to provide good quality care at the end of life.
- Hoel H, Skjaker SA, Haagensen R, Stavem Kl. Decisions to withhold or withdraw llife-sustaining treatment in a Norwegian intensive care unit. Acta Anaesthesiol Scand. 2014; 58:329-36.
- Kranidiotis G, Gerovasili V, Tasoulis A, Tripodaki E, Vasileiadis I, Magira E, et al. End-of-life decisions in Greek intensive care units: a multicenter cohort study. Crit Care. 2010; 14:R228.
- Lesieur O, Leloup M, González F, Mamzer MF; EPILAT study group. Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units. Ann Intensive Care. 2015; 5:15.