The chronically critically ill: to save or let die?

Critically ill patients admitted to an intensive care unit (ICU) are rapidly evaluated, and aggressive management is immediately instituted. They are intubated and placed on mechanical ventilation, and invasive monitoring is begun. Many patients are successfully treated and discharged from the ICU, but unfortunately a large percentage of the critically ill do not improve and become chronically critically ill. A high percentage of these patients do not survive in spite of extraordinary life support for weeks to months. The ICU health care team and the patient's family use their collective judgment to determine which patients are salvageable and which patients have no realistic chance to regain a good quality of life and therefore should have extraordinary life support withdrawn. This article examines why chronically critically ill patients die. We present a management strategy for improving the prognosis of the chronically critically ill patient by concentrating on exercise, nutrition, fluid management, emotional support, and adequate sleep. We address issues dealing with withholding and withdrawing extraordinary life support. We conclude by demonstrating how these concepts were applied in the case of a chronically critically ill young man with the acquired immunodeficiency syndrome (AIDS).