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Published on: September 20, 2018
[How to report the end-of-life decisions in the clinical record? Proposal of an "ABCD"]
1Uoc Anestesia e rianimazione, AO San Camillo-Forlanini, Roma.
Insights
Healthcare teams face challenges in documenting end-of-life care decisions in the ICU. A structured approach (Anamnesis, Balancing, Collegiality, Dialogue) ensures accurate medical record narratives for treatment withdrawal.
Area of Science:
- Medical Ethics
- Clinical Documentation
- Intensive Care Medicine
Context:
- End-of-life decision-making in Intensive Care Units (ICUs) presents complex challenges.
- Accurate and comprehensive medical record documentation is crucial for treatment withdrawal and palliative care transitions.
Purpose:
- To propose a structured framework for documenting end-of-life decisions in the ICU.
- To guide healthcare teams in creating clear and consistent clinical history narratives.
Summary:
- The study outlines a four-point mnemonic (A, B, C, D) for medical record documentation of end-of-life decisions.
- A=Anamnesis (clinical summary), B=Balancing (care reevaluation), C=Collegiality (shared decision-making), and D=Dialogue (patient/family communication) are essential components.
- Documentation responsibility can be delegated within the healthcare team, not solely resting on the ICU director.
Impact:
- Facilitates improved communication and shared understanding among healthcare teams, patients, and families.
- Enhances the quality and reliability of medical records pertaining to critical care transitions.
- Provides a standardized method for managing complex ethical and clinical decisions at the end of life.
Abstract:
Coping with the end of life decision making process in ICU, its complexity adds a challenge for the healthcare team: how to report in the medical record the events and reasoning that led to withholding or withdrawing treatments shifting from intensive to palliative care. Each healthcare team must select the best approach for managing the decision-making process and the necessary rules to ensure a correct clinical history narrative, indicating who must write and what has to be written. Taking into account the team organization, the report may be written not necessarily by the ICU director, but also by a staff physician as a spokesperson in the individual case. Regardless of the variability of each case, four points must be necessarily recorded recalling them with the first four letters of the alphabet (A, B, C, D) for an easier memorization: A= Anamnesis (clinical summary); B= Balancing (remodulation of care); C= Collegiality (sharing of decisions); D= Dialogue (conversation with the patient and/or family members).
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