Palliative care on the intensive care unit

Summary When futility of ongoing active treatments has become apparent in critically ill patients, effective palliative care must be instituted. Such care includes relief from the physical, emotional and spiritual aspects of dying. Five domains have been described; they are adequate pain and symptom relief, avoidance of inappropriate prolongation of dying, achieving a sense of control, having burdens relieved and strengthening relationships with loved ones. The mainstay of such care is frequently effective analgesia. Other physical provisions include sedation, temperature control, anti-emesis, reassurance (if conscious) and good basic care e.g. oral toilet, wound care, pressure area care, cleaning of soiled areas. Cultural and religious aspects must also be considered. Once analgesia and sedation are effective any intervention not advancing patients' goals (i.e. ‘to have a good death') should be eliminated. Critical care staff should also provide for the patient's family and have an understanding of the legalities of death e.g. certification, coroner, etc. and medico-legal examples of conflict. Senior clinicians therefore have a pivotal role in guiding an individual's care, minimizing conflict and educating others in both the practicalities of effective palliative care and the controversies surrounding the subject e.g. Doctrine of Double Effect and Euthanasia.