End-of-life care in the intensive care unit: can we do better?

Everywhere we turn these days, it seems that we are confronted with a new study that reports the dissatisfaction expressed by families with the quality of care received by their loved ones who have died while in the intensive care unit. It is difficult for caregivers to accept this information, which is now commonly reported both in published studies and in the lay press. As clinicians, most of us believe that we truly care about our patients and are trying, as best we can, to act in their best interest. No caregiver wants to hear that he or she does not do a good job when caring for dying patients and their families. It is ironic that clinicians recognize and accept the need for continuing education. Yet many clinicians resent the suggestion that the skills required for end-of-life care might be viewed in the same manner, as a lifelong learning process. It is unusual for physicians to identify end-of-life-care as an area of competency that can be improved or updated. Perhaps this is why end-of-life-care has been so difficult to teach to clinicians in training. Although many medical schools offer courses on the ethics of death and dying, formal training in end-of-life care skills is not routinely given in most postgraduate training programs. Learning these skills is a matter of on-the-job training for most caregivers. Not only have we been unable to measure any beneficial impact from education initiatives for end-of-life care, we have yet to identify clear indicators for end-of-life care. For caregivers, enhancing end-of-life skills may be a matter of improved listening skills, attention to the proper environment for end-of-life discussions, and a willingness to facilitate end-of-life decision-making. Encouraging caregivers to view end-of-life skills as a lifelong educational process, identifying core competencies in end-of-life care, and training clinicians in these skills are the challenges for the future. The quality of care our patients receive at the end of life will depend on our ability to answer these difficult questions.