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58 SAJCC November 2006, Vol. 22, No. 2 are requesting that they be given the opportunity opportunity the given be they that requesting are rights, and autonomy their of aware consumers, time, failure. a and enemy an as seen being death in resulted has biology human ordinary of bounds the beyond life extend to ability the technology, and pharmaceuticals in advances remarkable the of Because backgrounds. theoretical incommensurable and different from came they that fact the despite principles ethical on agree to able were ethicists medical cases, specific of examination the from principles deriving by ethics: to made medicine contribution amazing the Toulmin semi-paralysis. of state a into ethics cast initially beliefs and values incommensurable seemingly and competing with societies cultural multi- and Secularisation Enlightenment. the in experienced those exceeding challenges, particular posed has migration, and growth population industrialisation, communications, technology, science, in advances dramatic with civilisation, Modern practitioners. clinical for important be to considered are perseverance and fortitude compassion, of virtues The action. the performing person the of intent and character moral the on focusing age, this in revisited been have Ages, Middle the in expanded ethics, virtue Aristotle’s Holocaust. the and II War World after ratified were theories rights Human refined. and tested revised, criticised, posed, were situation the of ethics and hedonism, and emotion actions, of consequences the duty, and autonomy reason, variously emphasising theories particular and universal changes, economic and socio-political scientific, to response in Enlightenment, the of time the from particularly centuries, following the In beings. inanimate of smallest the to Himself God from stretching – being of chain the in link a as humankind seeing law, natural on based models constructed theorists centuries: ensuing the in modified were ethics Aristotlean and Platonic concerns. ethical present address to reinstated and modified refined, ages, the of knowledge and values beliefs, the reflect practice and Theories experience. professional and personal our by turn in augmented backgrounds, cultural and family historical, our by informed decisions moral approach all We civilisation. of dawn the since posited been have theories Ethical Shelley Schmollgruber, CCRN, MSc (Nursing), PhD, Lecturer Lecturer PhD, (Nursing), MSc Schmollgruber,CCRN, Shelley Lecturer Senior PhD, Langley,(Nursing), Gayle MSc Johannesburg Witwatersrand, the of University Sciences, Health of Faculty Education, Nursing of Department ARTICLE End-of-life care in intensive care units care intensive in care End-of-life 1 3 At the same same the At 2 has described described has as did Toulmin’s protagonists. Toulmin’s did as practitioners, direct and inform turn in will revised, and debated ethics, applied and theology moral of subjects the doubt no medicine; in existing tensions the and issues ethical with grapple theologians and ethicists organisations, professional society, players, role central the As unit. care intensive the in particularly most but medicine of areas all in out played being dilemmas ethical to led has This technology. and science on based death, and life health, managing of role 20th-century traditional medicine’s is this Countering pain. without and dignity with die to assistance requesting or directives advanced issuing and die will they how and when decide to after a decision to limit therapy. limit to decision a after so do now ICUs in die who patients of cent per Ninety 40%. than more at remain subgroups large certain for and ICUs, in 20% around at constant remained have rates mortality advances, medical Despite interventions. care health of excellence the and ethics of theory the to add so, doing in and, decisions humane and ethical make to order in bear to expertise and experience knowledge, ethical and professional their bring to called are professionals care Health intensively. care to able also are who care, intensive in experts by staffed are They places. special are ICUs arena ethical an as ICU The ICU. the in central be also should that resources support and making decision the of part central a be to committee ethical an of formation the advocate we response, a As care. patient disadvantage markedly to potential with process contested and fraught a frequently is making Decision- care. of face human the are they and process decision-making ethical actual the in involved persons primary the are nurses and doctors family, patient, life, of end the at However, involved. also are staff technical and laboratory counsellors, pastoral managers, psychologists, workers, social drama; the in characters only the not are They care. end-of-life in area this in roles central out play who persons the discuss will we Thereafter, area. this discuss first will we environment, different very a is unit care intensive the Because 7 7

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11 acknowledge the complexity of ethical 13 Staffing ratios and the staff ratio mix are 12 approach: respect for autonomy, non-maleficence, beneficence and justice, and considerations of risk/ benefit from which rules and particular judgements can be weighed and selected. However, they emphasise that, in moral reasoning, appeals to principles, rules, rights, virtues, passions, analogies and paradigms are registered ICU nurses. Severity of the patient’s illness is a cause for concern, dealing as we are with both First- and Third-World circumstances. HIV/AIDS affects a significant proportion of the population, posing the threat of sepsis in immune-compromised individuals. Multiple trauma resulting from high levels of violence, motor vehicle accidents and patient intentionality – the suicide rate in all populations is rising – also impact on the acuity of patients in ICUs. All these factors increase the likelihood that palliative care will be necessary, and decisions as to when and how to withhold or withdraw treatment are becoming increasingly important in ICUs. Applied ethics Applied ethics relies on the common morality. The widely shared values and conventions of society, national and international codes of research and professional ethics, governmental and institutional policies and various ethical theories as well as the character of the person or ethical agent inform decision making in medical ethics. Beauchamp and Childress decision making. They advocate a principle-orientated High levels of chronicity and co-morbidity (HIV/ AIDS-related diseases, tuberculosis, renal, endocrine and cardiac disease) in populations require multiple interventions and present practitioners with complex and difficult decisions. Open units, those staffed by different specialists, also present particular problems. Different regimens and protocols favoured by different specialists place burdens on nursing staff. In South Africa, the government policy privileging primary health care and budgetary constraints imposed on tertiary care present management with a conundrum as to how to ensure adequate services for primary, secondary and specialist services within one institution. The continued exodus of trained and experienced nurses is affecting all levels of health care. Trained ICU nurses are in particular demand, however, and due to poor salaries and working conditions they are leaving the country at an alarming rate. Currently only 25% of nurses staffing ICUs are registered as critical care nurses. matters of concern, and moves are afoot to increase the staff complement by including sub-professional categories of nurses in units to address the paucity of litigation have severely impacted on the ability to offer care. These 6 Unfortunately, clinicians may fail 8

9 survey of critical care nurses in the USA 10 more information and decision making be shared with patients or their surrogates, and the increase in This has had a huge impact on end-of-life decisions, and decision making is becoming increasingly complex. Other factors impinge on ethical decision making in critical care practice: the cost of health care due to shrinking financial and personnel resources and managed health care, the increasing emphasis on patient rights and autonomy, the requirement that The current situation in intensive care units Science and technology have progressed beyond belief, particularly in the area of pharmacology and medicine. surpassing most other clinical procedures. The physical, psychosocial and spiritual needs of the acutely ill individual need to be addressed, and this requires extraordinary expertise in communication and information giving, comfort care, and pharmacological management. patient’s suffering. careTo for the patient who is approaching death, ICU clinicians need to remember that death is part of life, not an enemy to be defeated; that palliative care is part of intensive care and requires a physical, moral, psychological and interpersonal intensity Asch’s revealed that almost 20% of more than 1 000 respondents reported engaging in what they considered euthanasia or assisted suicide, or in hastening death in response to a perceived overuse of technology or over- aggressive treatment, to relieve suffering or counter the perception of physician unresponsiveness to the and diversity in the process of withdrawal as well as who is charged with withdrawing treatment. differences have been attributed to professional, personal, social and attitudinal attributes of the caregivers, including specialty status or whether the patient has a unit or private attending physician. decision-making may also be a response to counter- transference. Inconsistent practices have been noted with regard to decisions to withdraw or withhold treatment. Differences have been found in judgements about the appropriate level of care for critically ill patients can influence their clinical responses in issues of life and death. Good communication is a matter of insight and self-awareness, not just language skills. In many cases, clinicians are forced to confront their own limitations, their memories of personal loss or their own mortality. Withdrawal and avoidance with unilateral Death and discussion about end-of-life care are common in ICU settings, yet these conversations are often difficult. The ICU ethos is orientated to saving lives, and acknowledging that death is approaching may be difficult. to appreciate how their personal emotions and values Pg 58-67.indd 59 Pg 58-67.indd 60

60 SAJCC November 2006, Vol. 22, No. 2 shared by all human beings. It is perhaps the fear most most fear the perhaps is It beings. human all by shared one is pain unbearable and uncontrollable of fear The studied. categories disease all in found were pain of levels important clinically died, who patients Among pain. experienced they that surrogates through or study SUPPORT large the in patients the of half underestimated; frequently is Pain care. health private in however, common, is practice this ICUs; specialist to admitted be not should survive to unlikely are who Patients outcome. probable the and admission from benefit to likely are they whether determine to measurements evaluative other and score evaluation health chronic and physiology acute an calculating after admitted generally are Patients systems. organ vital more or one of failure implies which ill critically are ICU an in patients definition, By patient The ICU the in players role The ICU. the in dying of process the negotiate families and patients assist to team multi-disciplinary the for help provide and published been have care end-of-life for guidelines patients. ill critically all for appropriate as seen is units care intensive comprehensive in care palliative of Integration imminent. obviously is death until patients care intensive for care palliative postponing of problems the exposed has evidence of body growing A concerns. broader these address must should rendered care All implications. societal and institutional professional, has but decision moral private a not is die to person a assisting intentionally that and caring; intensively means care intensive that alleviated; is anxiety that and pain from free and comfortable is person dying the that ensure to needed is care compassionate adequate, that ICU; the in person important most the is patient the and important is autonomy personal that life; prolong to means extraordinary use to required not are we and circumstances of set every in value overriding the not is life sacred, while that person; the of worth the undermine that made be cannot choices and compassionate be to called are we Christians, good; basic a life all consider and life of stewards be to required are persons and God from gift sacred a is life that include morality Christian in convictions Basic virtue. personal and tradition moral experience, scripture, considers also but sources these on relies making decision moral Christian allocation. resource of decisions clinician’s the informs justice thinking. moral in together linked be should particular more the and general more The blended. be to need frequently and supportive mutually regularly cited by persons seeking physician-assisted physician-assisted seeking persons by cited regularly 16,17 15

19 reported either directly directly either reported 13 The principle of of principle The 14 that, as as that, 6 6 Detailed Detailed 18

6

spiritual reassurance would be appreciated, and if so so if and appreciated, be would reassurance spiritual whether asked be should patient and family The family. the and patient the for both important as just is control of sense their enhance and done being is what explain fear, their alleviate can who practitioner nursing trusted and known a However, alone. them leave won’t and them, for and with pray them, to speak and touch will them, beside is trusted and known someone that know to patient the for comforting is it ideal; is patient the with members family of presence The die. to person a assisting intentionally on prohibition absolute an mean not might life of dignity and sanctity the respect to duty the that suggesting Nelson, and Connors and McCormick cases. certain in moral be might suicide assisted that suggested have ethicists Christian some years, support. and sympathy companionship, for request a rather is euthanasia for request a that noted II Paul John Pope death; causing intentionally and peacefully die to person the assisting between line a drawn consistently have medicine Western and Church Catholic the nonetheless, directives; advanced of use the supported has teaching Catholic effect’. double ‘the – life shorten to serves this if even experts, ethical and medical all by recommended is suffering, alleviate to calibrated doses in Morphine, analgesia. to analogous not is sedation that remembered be must It euthanasia. or suicide opinions are held by the Bishops interpreting the the interpreting Bishops the by held are opinions conflicting USA, the In controversial. remains nutrition and hydration with continue to whether decision The suffering. humanise to order in care emotional and spiritual compassion, include must it interventions; medical to limited be cannot Care this. ensure to necessary as upward calibrated be should and distress, and fear pain, alleviate can analgesia and Sedation covered. and dressed be should patient the – preserved be should Modesty family. the by her or him to access or movement hindering instrumentation medical and technical unnecessary without comfortably positioned be patient the that requires comfort and care) mouth and hair (skin, hygiene basic to attention and possible, if removed be should lines invasive and Extraneous avoided. be should interventions painful and Intrusive dignity. with dying means inevitably death good A it. of aware be she or he should patient the for terrifying more much how and this, noticing family the for distressing How 2005). communication, (personal person dying the with alone her leaving she lonely very how mentioned patients dying for caring in experience her of wrote who nurse ICU One bedside. the at needed also are team the of members Other wished. as person the anoint or confession hear Eucharist, the administer family, and patient the counsel to called be should religion of minister a felt – doctors and nurses would pass by the cubicle cubicle the by pass would nurses and doctors – felt 15 cite Maguire, Curran, Cahill Cahill Curran, Maguire, cite 20,21 The official official The 15 In recent recent In

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62 SAJCC November 2006, Vol. 22, No. 2 but also helps to prepare them for likely changes. changes. likely for them prepare to helps also but one loved their of care the in them includes only not know to right the have who those to status patient’s difficult, extraordinarily is prognosis accurate that conceded is It family. the with and team the of members all with possible, if patient, the to – communicated regularly be should progress and diagnosis patient’s The paramount. is admission of time the from communication regular Ongoing, outset. the from information received has family his and patient the if avoided be can impasse an cases, most In arises. difficulty a this, pursue to elects family his or patient the and cost or suffering of burden unacceptable an in result will but benefit of prospect small a offers intervention an If burdensome. too is treatment medical when decide to right a has surrogate or patient competent The prognosis. patient’s a establish to useful be may therapy of trials time-limited withdrawn; be to having of fear for up’. ‘giving as seen be can withdrawing and difficult, less appears often withholding difficulties; pose treatment withholding and withdrawing Both treatment. such provide to obliged not is clinician the benefit, any provide will interventions specific that evidence no is there If possibilities. all of exploration the and empathy demand situations These treatment. life-sustaining recommended any refuse to right the has she or he decisions, make to able and conscious is patient the If consent. informed and disclosure truth-telling, respect, for rules the incorporates autonomy of principle The interventions. or procedures for consent requesting merely beyond goes family) the (and person the of identity autonomous The dyspnoea. alleviate can positioning and Oxygen distressed. is patient the if used be must restraints physical than rather Sedation suffering. in result not will this that given reassurance and family the and patient the to explained be should this treatment, withdraw to made been has decision the When care. mouth good and conscious) (if ice with moist kept mouth patient’s the and removed be should it distress causes tube nasogastric the if Generally, patient. the to afforded benefit the by but feel clinicians the how by determined be not should Treatment them. for burdensome too not is this provided nutrition, and hydration of deprived be not should patients impaired mentally consequently and death, to starve to patient competent a allow to inhuman is it that maintains Ford removed. be should tubes feeding burdensome, if that insist May, William and Finnis John including Others, love. demonstrate and care normal are hydration and nutrition that maintaining some Workers, Care Health for Charter Vatican’s 23 However, treatments should not be withheld withheld be not should treatments However, 24 but communicating the the communicating but 21

22 21

– whether medical insurance will cover the expense of of expense the cover will insurance medical whether – intervene also concerns Financial work. and home family, patient, the towards exist responsibilities conflicting and Pressing done. being is much too or enough whether and experienced, being is pain much how necessary, are these whether procedures, certain to subjected being is she or he why feeling, is patient the what about anxiety includes Concern distrust. and confusion causes also care palliative and active between changes abrupt seeming the and sounds and movements high-technology, its with milieu, ICU The patient. the and family the of behalf on making decision for responsibility assume should family the from person which as well as caregivers various the of authority and roles the about exists Confusion this. for grounds no be might there though even miracle’, ‘a for hope to continues family the given, is care extraordinary active where unit a as perceived is ICU the Because outcome. the to responses envisaged own their or disability, permanent death, whether – outcome the of fear also is There present. are responsibility of assumption and guilt primitive distrust, and responsibilities conflicting anxiety; and guilt hope, confusion, experiences also family The exist. reality of denial and disbelief fear, experience, traumatic any with As members family The person die, be of comfort to them. They can go away away go can They them. to comfort of be die, person the should will, but distress and anxiety their assuage to helps only not care with assist to possible, if and, one loved their with be to ability The members. family all to open be should visiting possible, is as far As distrust. with react often members family instituted abruptly is communication when Consequently, anxious. and distressed are families that and traumatic and sudden frequently is units to admission that facts the by communication. with struggle practitioners ICU many that indicates date to Research one. loved their for caring of process the of part and valued are they that feel members family that ensure will life, and preferences needs, patient’s the about asking as well as guarded), if (even progress envisaged and status current patient’s the interventions, ICUs. many in improvement needs it that suggests evidence concern, pre-eminent a as communication rank families their and patients ill critically Although them. to explained treatment or prognosis diagnosis, the comprehend to failed patients care intensive of families the half over that found attention. careful need team, the of members all from also but member family the for caring of charge in clinician the from only not support, and communication information, ongoing and Immediate breadwinner. the be patient the should earnings of loss and treatment, 9

6,24 24 Explaining equipment, equipment, Explaining This is complicated complicated is This 25 Azoulay Azoulay et al 11/16/06 1:50:44 PM . 26

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27 For example, 14 However, 14 These include all those 14 quotes Janssens and McCormick 27 Is omitting treatment rather than 26 more frequently than turning off respirators), leading to the patient being unable to sustain a blood pressure appropriate means of caring for this person is palliative care. Schotsmans in stating that proportionality is a question of the relationship between end and good. There must not be an intrinsic contradiction between the basic good that we hope to preserve and the means used to obtain the end. According to the principle of double effect, a difference exists between the intention and what can be envisaged as a possible side-effect of an action. Some acts may be considered wrong in themselves (for example, willfully killing the innocent or a patient who is likely to survive). But, if the morality of the case is to be assessed, the agent must be deemed less responsible for the foreseen or indirect consequences of an action. The conundrum lies in distinguishing between active killing, letting die, and hastening death by an action. It is therefore not the active treatment that is under question, but the agent withholding or withdrawing treatment. sustaining life morally the same? Giving increasing doses of analgesia and thus (inadvertently) hastening death is acknowledged to be moral. intravenous inotropes are regularly withdrawn (far It is never obligatory to use medical measures which are morally ‘extraordinary’ to preserve life; concepts such as ordinary and extraordinary treatment have evolved into the concept of proportionate and disproportionate means. means which are experimental, involve excessive physical pain, subject the person to extreme distress, discomfort or expense, or merely serve to prolong life. This distinction requires clarification, as means that are thought of as medically ordinary may be morally extraordinary. Owing to the rapid advances of medical treatment, the language of ordinary and extraordinary may not be appropriate. Theologians usually designate ordinary means as those that can be obtained and used without great difficulty. Ordinary means may become extraordinary depending on the circumstances. The immediate and long-term benefits and risks to the patient must be assessed; a reasonable hope of recovery, the ability to interact in familiar surroundings and the bearable amount of discomfort entailed in providing life support must be considered, as well as the patient’s long-term quality of life. a person in an irreversible coma, with terminal cancer or who has Cheyne-Stokes respiration should not be subjected to artificial means of maintaining life. The Difficult decisions regarding care at the end of life This places a 12 Medical specialists, 25 The intense environment, the severity of the patient’s illness, conflicting prescriptions, ethical conundrums, unremitting responsibility and disparate expectations lead to dissent and frustration, which impact negatively on the clinical staff and lead to burnout. decision making and can result in a clash of cultural, religious and professional values. schooled in a previous model, are apt to make decisions on their own and leave the nursing practitioners to effect the action and to explain the decision to the family. experienced and even unqualified staff. burden on the experienced and specialist practitioners. One of the challenges facing health professionals is working in a multi-disciplinary team. Blurring of roles, the need for continuous dialogue, and moving from a hierarchical to a collegial model method requires shared needless violence and accidents, patients succumbing to overwhelming sepsis after relatively benign surgery – all reinforce their helplessness in the face of death. The current shortage of trained and experienced staff in all South African hospitals means that units are frequently staffed by agency nurses or inadequately issues surrounding caring for the critically or terminally ill. The practice of triage – refusing certain people care because of their perceived poor prognosis – leaves people feeling frustrated and angry. Babies who die because they are deemed too immature to survive, innocent persons and the young dying because of practitioners The emotional intensity, technical and problem-solving skills and physical effort required in caring for the patient means that clinicians are subject to emotional stress. The pain, distress and high mortality rates ensure that they are continually aware of the ethical the family, instil hope, unite them and the patient in prayer and the sacraments, help the family and patient to deal with unresolved issues, guilt and reconciliation, and assist the clinicians in explaining options. The medical and nursing Families need to be reassured that everything possible is being done to ensure the comfort of the patient. Even when active treatment is stopped, they need to know that the person isn’t being abandoned and that the best treatment is being offered for his or her current condition. A trusted spiritual advisor can help support knowing that they did all they could to help. Families do, however, need to accept that the patient is in the unit to receive medical and nursing care. This requires that they may need to be absent during periods when care activities are being carried out. These facts need to be empathically but firmly enforced. 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64 SAJCC November 2006, Vol. 22, No. 2 and group beliefs, values and aims would contribute contribute would aims and values beliefs, group and personal of discussion and Identification unit. the within values sound reinforce and dilemmas ethical addressing in clinicians assist could group The options. proposed of acceptance and understanding family aid to developed be could care palliative and active of methods and aims the and treatments terms, medical explaining material Written died. has patient the after or before care pastoral or support social counselling, for members family to suggested be could resources Referral available. options the explaining committee ethics the of member a by options care negotiate and evaluate to assisted be could members Family action. each of consequences likely the and available options discuss and consider to family and patient the assist could counsellor the wishes, patient’s the of appraised be to need team clinical and family the As decisions. their of implications legal and ethical the to as counselled be could treatment further continuing or terminating contemplating and conscious are who Patients value. inestimable of be would counsellors pastoral and ethicists clinicians, comprising sub-committee a of presence The committee ethics dedicated The staff. clinical the educate and support and families and patients to afforded care the enhance to sub-committee dedicated a for advocate would we Consequently, practitioners. clinical of experience daily the are that negotiations normal the than more require this like Dilemmas staff. clinical the among distress extreme caused This die. to allowed and respiration artificial off taken was he Reluctantly, unit. the in treatment from benefit would who patients other admit to pressure is There muscles. the of paralysis the in change no with and respirator the off him wean to attempts continuous with months 6 further a for continued was ventilation where hospital government a to transferred was he and exhausted been had insurance Medical own. his on breathe to unable was he conscious, fully being Despite syndrome. Guillain-Barré with diagnosed patient a of hand, first experienced case, the by illustrated is dilemma Another ventilator. a of removal dramatic the than staff and family patients, for distressing less far is inotropes withdrawing token, same the By means)? ordinary (i.e. procedure distressing minimally and accessible easily inexpensive, relatively a by maintained being is pressure blood patient’s the that considering moral, considered be this Would patient. the of death the cause to acting as construed be can This action. the of consequence direct a as dying and disciplinary cohesion and encourage the development development the encourage and cohesion disciplinary multi- and collaboration respect, interpersonal to 12. 9. 5.

2. 10. 16. 13. 4.

7. 3.

15. 14. 11. 6. 8. person, as well as the patient’s family. Apart from from Apart family. patient’s the as well as person, important most and central the as patient, the on focused and ethical compassionate, be must offered Care so. do frequently patients ideal, not is ICU an in dying though unit,and the in necessary as advocated being increasingly is care Palliative miracles. as well as distress and emotion with fraught dramatic, are therein experiences the and milieu ICU the conclusion, In Conclusion enriched. be would practice and theory of circle the again, once and, theorists theology moral of benefit the to theory inform could experience clinical and evidence empirical manner, this In concerned. all to acceptable plans care institute to institutions health of management and clinicians assist could care end-of-life and palliative in practice best and current into Research burnout. prevent to staff to debriefing and counselling supportive offering in workers social as such staff support join also could group core This making. decision in skill and knowledge ethical promote to staff the to offered be could education In-service care. of plan a at arriving and family and patient the with negotiating and communicating of tasks difficult the in help to compiled be could clinicians of guidance the for protocols and Policies virtues. personal of 1. care. end-of-life and palliative improved family and patient the afford as well as care ethical enhance would ethicists and team disciplinary multi- the of members comprising sub-committee committed A patients. their of treatment the in principles ethical exercising in practised be must clinicians virtues, and skills necessary the cultivating

CONNECT Africa. South nursing: care critical of Perspectives E. Nel S, Schmollgruber J, Scribante Fins JJ, Solomon MZ. Communication in intensive care settings: the challenge of futility of challenge the settings: care intensive in Communication MZ. Solomon JJ, Fins Heart unit. care intensive medical a in outcomes patient and collaboration interdisciplinary between association The J. Johnson J, Richeson C. Phelps S. Ryan J. Baggs Medicine Toulmin S. How medicine saved the life of ethics. ethics. of life the saved medicine ToulminHow S. Asch DA. The role of critical care nurses in euthanasia and assisted suicide. assisted and euthanasia in nurses care critical of role The DA. Asch Dimensions unit. care intensive the in care GP.end-of-life Ciccarello improve to Strategies JF.Childress TL, Beauchamp intensive care in major medical centres. centres. medical major in care intensive from outcome of evaluation An J. Zimmerman WagnerW.D, E. Knaus Draper Truog RD, Cist AFM, Brackett SE, Brackett AFM, TruogCist RD, updated. life- of end the at care affecting values and models administrative care: of covenant the and intensivists Surgeons, RM. Stewart S, Streat TG, Buchman J, Cassell and PT,RB. McCormick Connors 64-75. November: 1996; perspective. Catholic Roman a dignity: with Death TR. Kopfensteiner 1994. Press, University nightmares. and dreams containment: cost of era an in practice care critical Ethical S. Bhagwanjee Crit now? we are Where unit: care intensive the in care End-of-life MD. Danis JE, Nelson Med disputes. Curtis R, Patrick DL, Shannon SE, Treece PD, Engelberg RA, Rubenfeld GD. The family The GD. Rubenfeld RA, TreeceEngelberg SE, PD, Shannon DL, Patrick R, Curtis care unit: Opportunities for improvement. for Opportunities unit: care intensive the in care life of end about communication improve to focus a as conference Care Medicine. Care Critical of Society the of Committee Ethics The unit: care intensive Mallia P. Biomedical ethics: the basic principles. principles. basic P.the Mallia ethics: Biomedical Care Community 1996; Med Lung 1982; Crit Med 2001; Crit 334: 1992; – of South The Care 2001: Care Critical 1374-1379. 25: . New York: Paulist Press, 2002. York:Press, New Paulist . 29: 21 World 736-750. Med 2332-2348. African Med (1): 18-24. (1): 29 Care (2): suppl, 2-9. suppl, (2): 2003: of 2001; Critical Journal Nursing Facing 31: Principles 29 1551-1559. (2): suppl, 10 -15. 10 suppl, (2): Care et of 2003; Ethical al. Critical Recommendations for end-of life care in the in care life end-of for Recommendations Nursing of Ann 22 Crit Biomedical Issues: (5): 216-222. (5): Care Intern Care 2004; 2004; BMJ Perspectives Dimensions Med Med 3 Ethics 2003: (4): 111-115. (4): 20: 2001; 1986; 50-52. . 4th ed. Oxford: Oxford Oxford: ed. 4th . 11 29 104: in of (5): 142-145. (5): (2): suppl, 26-33. suppl, (2): Biology Character, 410-418. Linacre and N Choices Quarterly Engl 11/16/06 1:50:45 PM J Crit

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Difficulty in swallowing and pooling of oropharyngeal Knowing and following the patient’s wishes for end- secretions with loss of gag reflex of-life care Promoting earlier cessation of treatment or not initiating aggressive treatment at all 24. Signs and symptoms of impending death • Increasing weakness and fatigue • Facilitators to providing a good death • Making environmental changes to promote dying with dignity • Being present • Managing the patient’s pain and discomfort • • Communicating effectively as a health care team. Although it may not be practical, the intensive care environment should be such as to allow the family and significant others privacy and access without disturbing the other patients. It is also recommended to advise the family that the time of death is unpredictable and to educate them about the usual course of a comfortable and peaceful death. • List of sources consulted 27. 26.

25.

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The last hours of living inpriorities the ICU – of care for critical care nurses ARTICLE Division of Nursing University and of Midwifery, Cape Town Nicola A Fouché, MSc, AUDNE, Dip Intensive Care Nursing, RN, RM, Lecturer in Critical Care Nursing and mourning prolonged. may result in significant personal and family growth; if it is done poorly, closure to life may be incomplete, all involved may suffer, and bereavement may be difficult say goodbye. While we are privileged and honoured to be with the patient and family at this time, we have only one chance to do it correctly. If it is done well it receive. some of the most significant times in our patients’ lives, allowing opportunities to finish business, create final memories, achieve spiritual peace, and of course change to those of care and comfort. It should be stressed to the family that this does not mean any reduction in the level of care that the patient will Once it has been decided that additional medical intervention will not assist the patient, the priorities a period of time. It may be an expected outcome, or it may become evident that further intervention and continuation of treatment is futile and distressing for the patient, the family, and especially the nursing staff. immediately after an emergency admission and there is little time to prepare either the patient or the family. In the majority of cases, however, death occurs after Critical care is associated with a high mortality rate. While this varies, overall it is likely to be between 15% and 25%. 17. 22. 23. 19. 21. 20. 18. Pg 58-67.indd 65