Background

Intensivists must provide enough analgesia and sedation to ensure dying patients receive good palliative care. However, if it is perceived that too much is given, they risk prosecution for committing euthanasia. The goal of this study is to develop consensus guidelines on analgesia and sedation in dying intensive care unit patients that help distinguish palliative care from euthanasia.

Methods

Using the Delphi technique, panelists rated levels of agreement with statements describing how analgesics and sedatives should be given to dying ICU patients and how palliative care should be distinguished from euthanasia. Participants were drawn from 3 panels: 1) Canadian Academic Adult Intensive Care Fellowship program directors and Intensive Care division chiefs (N = 9); 2) Deputy chief provincial coroners (N = 5); 3) Validation panel of Intensivists attending the Canadian Critical Care Trials Group meeting (N = 12).

Results

After three Delphi rounds, consensus was achieved on 16 statements encompassing the role of palliative care in the intensive care unit, the management of pain and suffering, current areas of controversy, and ways of improving palliative care in the ICU.

Discussion

The goal of this study is to develop consensus guidelines on analgesia and sedation that consider the unique challenges encountered when palliating dying ICU patients, and help distinguish palliative care from euthanasia in the ICU setting. The guidelines are not intended to argue for or against the legalization of euthanasia. Our hope is that the guidelines will decrease the confusion and anxiety regarding the use of opiates and sedatives at the end of life and thereby improve the quality of care received by dying patients. To meet this goal, we have divided the guidelines into sections describing palliative care in the ICU setting, management of pain and suffering, areas of controversy, and ways of improving palliative care in the ICU.

A recent review of the literature by Ostermann et al. [28] revealed the paucity of good randomized controlled trials on sedation in ICU patients. Research has revealed problems in alleviating pain even among skilled palliative care providers [1-4,29,30] and there is no proof in the current literature that Intensivists are better at relieving their dying patients' distress than other physicians [3]. Healthcare providers withdrawing treatments from dying patients frequently encounter apprehension and concern from surviving family members about how their loved one's pain and distress will be treated. In these situations of withdrawal of life-sustaining treatment, both healthcare providers and family members hope for a speedy, comfortable death in which pain and other distressing symptoms are well controlled and the process of dying is accomplished in peace with loved ones at the bedside [17]. However, questions by family members often reveal concern that their loved one's final moments will be filled with suffering, or, alternatively, that drugs such as opiates and benzodiazepines given by the healthcare team will unduly hasten the dying process and/or kill their loved one [1-3],[7-16,32,33].

Cases of euthanasia committed by healthcare providers have occurred and receive widespread media attention [9-15]. These highly publicized cases of euthanasia, restrictive prescribing legislation, and increased scrutiny by coroners, licensing bodies, families and the public, lead healthcare providers to under-treat the pain and symptoms of their dying patients [1-16,32,33]. Furthermore, fears of being misunderstood - of having their intent to palliate mistaken for an intent to kill - are currently being exacerbated by debates/articles in the medical literature [34-36]. The authors of these articles seek to promote the legalization of euthanasia by misappropriating ethical principles such as the Principle of Double Effect in order to confuse their colleagues and diminish the fundamental and very real differences between the practices of palliation and euthanasia [34-36]. An unintended consequence may be to increase the reluctance on the part of health care providers to administer adequate analgesia and sedation to dying patients.

The US Society for Critical Care Medicine practice parameters [18] and in Canada, the Ontario Chief Coroner's memo on palliative care [19], have established practice parameters on analgesia and sedation. Unlike our guidelines, the SCCM practice parameters [18] do not discuss the use of opiates and sedatives in dying patients, while the Ontario Chief Coroner's guidelines[19] do not relate to the ICU. Brody et al. [37] also developed guidelines for compassionate management in withdrawing intensive life-sustaining treatments; however, these guidelines were based on a literature review, did not use consensus methodology or involve a national panel of Intensivists and only represented the authors' opinions. Furthermore, Brody et al. [37] do not attempt to address how palliative care can be distinguished from euthanasia in the ICU.

To our knowledge, our consensus guidelines on analgesia and sedation in dying ICU patients are the first of their kind developed using consensus methods and involving coroners. The use of consensus methodology and the participation of coroners will hopefully serve to clarify the areas of controversy, their nature and help us resolve these dilemmas in the future. As well, participation by coroners will hopefully result in increased understanding of the difficulties faced both by those caring for the dying and for those asked to review the care received - for it is only through open dialogue that we can ever hope overcome any doubts about intent - to palliate or to kill - and thereby improve the quality of end-of-life care.

This study has three main limitations. First, our guidelines use a small group of expert Intensivists and Coroners to focus attention on how pain and suffering ought to be palliated at the end of life. While our panel sizes were small, saturation of responses occurred in each Delphi round, a sign of credibility (internal validity). Although we attempted to validate our consensus statements by using an independent panel of Intensivists, this panel was also small. While the validation panel was a convenience sample, panelists were representative of Intensivists across the country and agreed with all of the developed consensus statements, a sign of transferability (external validity).

Second, our consensus guidelines are physician-based. They represent an initial attempt to improve the quality of end-of-life care in the ICU by describing best practice in regards to the administration of analgesics and sedatives to dying patients. In order to improve the overall quality of end-of-life care in the ICU, these consensus guidelines need to be incorporated into an overall program to educate the ICU staff in caring for dying patients. These guidelines can then be discussed and modified as needed by other members of the ICU team

Third, our consensus guidelines are developed from a professional and not a patient's perspective. Intensivists' assumptions on how to best treat pain and suffering at the end of life may differ markedly from patients' and families' lived experiences. More research is needed to explore the patient's and family's perspective on how palliative care can be improved in the ICU.

Conclusion

Consensus guidelines were developed to guide the administration of analgesics and sedatives to dying ICU patients and to help distinguish palliative care from euthanasia.

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