Intensive Care
Palliative Care
Intensive Care Medicine

Palliative Care Principles in Intensive Care

Palliative care in the intensive care unit (ICU) represents a fundamental component of high-quality critical care, focus... CICM Fellowship Written, CICM Fellow

49 min read
Quality score
54/56

Clinical board

A visual summary of the highest-yield teaching signals on this page.

Urgent signals

Safety-critical features pulled from the topic metadata.

  • Prolonged ICU stay (greater than 14 days) with minimal improvement
  • Multiorgan failure requiring multiple organ support
  • Severe neurological injury with poor prognosis
  • Advanced comorbidities and functional decline

Exam focus

Current exam surfaces linked to this topic.

  • CICM Fellowship Written
  • CICM Fellowship Viva

Editorial and exam context

CICM Fellowship Written
CICM Fellowship Viva
Clinical reference article

Palliative Care Principles in Intensive Care

Clinical Overview

Palliative care in the intensive care unit (ICU) represents a fundamental component of high-quality critical care, focusing on relief of suffering and improvement of quality of life for patients with life-limiting illnesses. Unlike traditional critical care which prioritizes survival and organ function, palliative care emphasizes symptom control, communication, and alignment of treatment with patient goals and values.

Key Concept: The integration of palliative care principles into ICU practice is not about "giving up" but rather about ensuring that care is patient-centered, goals-aligned, and compassionate regardless of outcome.

Definition: The World Health Organization (WHO) defines palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. [1,2]

Epidemiology: Studies indicate that up to 20% of ICU patients die during their admission, and an additional 10-15% die within 6 months of discharge. [3,4] Among ICU nonsurvivors, approximately half have decisions to limit life-sustaining therapy, with variation across regions and institutions. [5,6]

ICU Relevance: Palliative care principles are particularly relevant in the ICU setting due to the high mortality rate, prevalence of patients with advanced chronic illness, and the need for complex, value-laden decisions about life-sustaining treatments. Early integration of palliative care in the ICU has been shown to improve quality of care, reduce length of stay, and increase satisfaction among families. [7,8]

WHO Definition and Core Principles

WHO Definition of Palliative Care

The World Health Organization (WHO) provides the authoritative definition of palliative care that guides practice globally:

"Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual." [1]

Key Elements:

  • Prevention and relief of suffering
  • Early identification (NOT only at end of life)
  • Impeccable assessment and treatment of pain
  • Holistic approach (physical, psychosocial, spiritual)
  • Patient and family-centered
  • Applicable across the disease trajectory

Palliative Care vs End-of-Life Care

A critical distinction exists between palliative care and end-of-life (EOL) care:

Palliative Care:

  • Appropriate ANY TIME during the disease course
  • Can be provided concurrently with life-prolonging therapies
  • Focus on quality of life, symptom management
  • NOT limited to patients with prognosis below 6 months
  • Emphasizes comprehensive assessment and management

End-of-Life Care:

  • Subset of palliative care for patients with prognosis of hours to days
  • Usually when death is imminent (below 48 hours)
  • Focus shifts to comfort measures only
  • Typically when life-sustaining treatments are withdrawn
  • Emphasis on peaceful death and family support

Clinical Significance: This distinction is crucial because palliative care can be initiated EARLY in the ICU course, alongside aggressive treatment, and does not signify "giving up." Patients can receive both full active ICU treatment AND palliative care simultaneously. [9,10]

Core Palliative Care Principles

1. Affirmation of Life and Regarding Death as Normal

  • Death is acknowledged as a natural process
  • Neither hastening nor postponing death
  • Value placed on dying with dignity

2. Relief of Pain and Distressing Symptoms

  • Impeccable assessment and treatment
  • Evidence-based pharmacologic and non-pharmacologic approaches
  • Regular reassessment and adjustment

3. Integration of Psychological and Spiritual Aspects

  • Holistic care addressing mind and spirit
  • Recognition of cultural and personal beliefs
  • Support for existential distress

4. Support System for Patient and Family

  • Care extends to the family unit
  • Bereavement support
  • Practical assistance

5. Enhancement of Quality of Life

  • Positive contribution throughout illness course
  • NOT limited to terminal phase
  • Active approach to living with illness

6. Appropriate for All Life-Threatening Illnesses

  • Cancer, organ failure, trauma, neurological conditions
  • Irrespective of age or diagnosis
  • Across all stages of disease

7. Not Limited to Symptom Management

  • May involve early investigations and interventions
  • Goal-directed treatment aligned with values
  • Preventive measures to minimize complications [1,2,11,12]

CICM Competencies: Communicator Domain

The College of Intensive Care Medicine (CICM) identifies communication as one of its core competencies, essential for effective practice in palliative care within the ICU.

CICM Communicator Domain Requirements

Core Competencies:

  • Establish rapport with patients, families, and healthcare team
  • Communicate effectively across diverse contexts and stakeholders
  • Conduct sensitive discussions about prognosis, goals of care, and end-of-life decisions
  • Facilitate family meetings and shared decision-making
  • Provide clear explanations of complex medical information
  • Manage conflict and difficult emotions
  • Document communication accurately and comprehensively

Communication Challenges in ICU Palliative Care

1. Acute vs Chronic Illness Paradigm

  • ICU patients often have acute decompensation of chronic illness
  • Families unprepared for rapid deterioration
  • Need for rapid adjustment of expectations

2. Multiple Stakeholders

  • Primary treating team (multiple intensivists)
  • Consultants (specialists, surgeons)
  • Nursing and allied health staff
  • Multiple family members with varying perspectives

3. Information Overload

  • Complex medical information delivered quickly
  • Emotional distress impairs comprehension
  • Need for repeated clarification

4. Uncertainty in Prognosis

  • ICU outcomes often uncertain
  • Difficulty predicting recovery or trajectory
  • Balancing hope with realism

5. Time Pressure

  • Urgent clinical decisions required
  • Limited availability of family members
  • Shift changes and staff rotation

6. Cultural and Language Barriers

  • Diverse cultural backgrounds
  • Language difficulties
  • Varying understanding of medical concepts

7. Conflict Management

  • Disagreements between family members
  • Different interpretations of patient's wishes
  • Ethical dilemmas requiring multidisciplinary input [13,14,15,16]

Symptom Control in ICU Palliative Care

Effective symptom management is the cornerstone of palliative care in the ICU. Patients receiving palliative care or undergoing withdrawal of life-sustaining therapy (WLST) frequently experience pain, dyspnea, delirium, and other distressing symptoms requiring expert management.

Pain Management

Epidemiology: Pain is experienced by up to 50% of ICU patients, with higher prevalence in surgical patients, trauma patients, and those with prolonged mechanical ventilation. [17,18]

Assessment Challenges:

  • Altered level of consciousness
  • Sedation and neuromuscular blockade
  • Communication barriers (endotracheal tube, cognitive impairment)
  • Physiologic signs unreliable (tachycardia, hypertension)

Assessment Tools:

  • Critical-Care Pain Observation Tool (CPOT)
  • Behavioral Pain Scale (BPS)
  • Numeric Rating Scale (NRS) when communication possible
  • Nonverbal cues and body language

Pharmacologic Management:

Opioids (First-Line):

  • Morphine: 2.5-5 mg IV/SC q4h PRN, titrated to effect
    • Active metabolite morphine-6-glucuronide (accumulates in renal failure)
    • Histamine release (causes hypotension in hemodynamically unstable)
  • Fentanyl: 25-100 mcg IV q1-2h PRN
    • Potent, rapid onset
    • No histamine release (suitable for hemodynamically unstable)
    • Transdermal patch for stable opioid requirements
  • Oxycodone: 5-10 mg PO q4-6h PRN (for extubated patients)
  • Methadone: For neuropathic pain or opioid tolerance (complex dosing, specialist input required)

Adjuvant Analgesics:

  • Paracetamol: 1g IV/PO q6-8h (max 4g/24h)
    • Additive effect with opioids
    • Reduces opioid requirements by 30-40%
  • NSAIDs (ketorolac): 15-30 mg IV q6h PRN
    • Contraindicated in renal failure, coagulopathy, peptic ulcer disease
  • Gabapentin/Pregabalin: For neuropathic pain
    • "Gabapentin: 100-300 mg PO q8h (titrated)"
    • "Pregabalin: 75-150 mg PO q12h (titrated)"
    • Monitor for sedation, especially with renal impairment
  • Ketamine: Subanesthetic infusion (0.1-0.3 mg/kg/h)
    • NMDA receptor antagonist
    • Opioid-sparing effect
    • Caution in patients with psychiatric history
  • Corticosteroids: Dexamethasone 4-8 mg IV/PO daily
    • Anti-inflammatory effect
    • Improves mood and appetite
    • Reduces peritumour edema, nerve compression pain

Non-Pharmacologic Approaches:

  • Repositioning and mobilization (where possible)
  • Music therapy and environmental modifications
  • Relaxation techniques
  • Therapeutic touch and massage (where culturally appropriate)
  • Removal of unnecessary devices and alarms

Special Considerations:

  • Renal failure: Reduce opioid doses, avoid morphine, use fentanyl or methadone
  • Hepatic failure: Reduce opioid doses, avoid morphine-6-glucuronide accumulation
  • Opioid tolerance: Higher doses required, rotate between opioids
  • Opioid-induced hyperalgesia: Consider opioid rotation, add ketamine

Dyspnea Management

Epidemiology: Dyspnea affects 30-50% of ICU patients, including those receiving mechanical ventilation, those with chronic respiratory conditions, and patients with terminal illness. [19,20]

Pathophysiology:

  • Hypoxemia (low PaO2)
  • Hypercapnia (elevated PaCO2)
  • Increased work of breathing
  • Anxiety and panic response
  • Air hunger sensation (chemoreceptor stimulation)
  • Respiratory muscle fatigue

Assessment:

  • Respiratory rate, use of accessory muscles
  • Oxygen saturation, ABG analysis
  • Patient-reported dyspnea (if able to communicate)
  • Visual Analogue Scale (VAS) or Numeric Rating Scale (NRS)
  • Behavioral cues (restlessness, agitation)

Pharmacologic Management:

Opioids (First-Line):

  • Morphine: 2.5-5 mg IV/SC q4h PRN (or infusion)
    • Reduces ventilatory drive (central respiratory depression)
    • Reduces anxiety associated with dyspnea
    • "Mechanism: μ-opioid receptor stimulation in medulla"
  • Fentanyl: 25-50 mcg IV q1-2h PRN
    • Useful for rapid titration
    • Minimal hypotension

Evidence: Systematic reviews demonstrate that opioids reduce dyspnea severity by 30-40% in patients with advanced illness, with minimal respiratory depression when appropriately titrated. [21,22,23]

Oxygen Therapy:

  • Target SpO2 88-92% in patients with COPD (avoid hyperoxic hypercapnia)
  • Target SpO2 92-96% in other patients
  • Use nasal cannula or face mask as tolerated
  • Non-rebreather mask for severe hypoxemia
  • High-flow nasal cannula (if available)

Benzodiazepines (For Anxiety Component):

  • Lorazepam: 0.5-1 mg IV/PO q4-6h PRN
  • Midazolam: 1-2.5 mg IV q1-2h PRN (or infusion 1-5 mg/h)
  • Useful when anxiety contributes significantly to dyspnea sensation
  • Caution: May cause sedation, respiratory depression when combined with opioids

Non-Pharmacologic Approaches:

  • Fan therapy: Cool air directed to face reduces dyspnea sensation (stimulates trigeminal nerve)
  • Upright positioning: 30-45 degrees, high Fowler's position
  • Relaxation techniques: Pursed-lip breathing, guided imagery
  • Music therapy: Reduces respiratory rate and anxiety
  • Acupressure: Pericardium 6 (P6) point may reduce dyspnea

Mechanical Ventilation Withdrawal: When withdrawing mechanical ventilation for terminal extubation or WLST:

  • Consider premedication: Morphine 5-10 mg IV + Midazolam 2-5 mg IV
  • Titrate to comfort, not specific respiratory parameters
  • Remove endotracheal tube (extubation) vs terminal wean
  • Terminal extubation typically results in death within minutes to hours
  • Continuous reassessment and titration required

Delirium Management

Epidemiology: ICU delirium affects 30-80% of ventilated patients, with higher rates in elderly patients, those with severe illness, and those requiring prolonged ICU stay. [24,25]

Types of Delirium:

  • Hypoactive: Lethargy, reduced responsiveness, withdrawal
  • Hyperactive: Agitation, hallucinations, delusions, restlessness
  • Mixed: Fluctuating between hypoactive and hyperactive

Risk Factors:

  • Advanced age (greater than 65 years)
  • Pre-existing cognitive impairment/dementia
  • Severe illness and organ failure
  • Prolonged mechanical ventilation
  • Sleep deprivation and ICU environment
  • Medications (sedatives, anticholinergics)
  • Infection, sepsis, metabolic disturbances

Assessment Tools:

  • Confusion Assessment Method for ICU (CAM-ICU)
  • Intensive Care Delirium Screening Checklist (ICDSC)
  • Regular assessments (at least once per shift)

Pharmacologic Management:

First-Line: Antipsychotics (for agitation/distress)

  • Haloperidol: 0.5-5 mg IV/IM q4-6h PRN

    • Butyrophenone antipsychotic
    • Typical antipsychotic
    • Effective for agitation, hallucinations
    • Monitor for QT prolongation, extrapyramidal symptoms
    • Lower doses in elderly (0.5-1 mg)

  • Olanzapine: 2.5-5 mg PO/IM q12-24h PRN

    • Atypical antipsychotic
    • Fewer extrapyramidal side effects
    • Caution in patients with antipsychotic sensitivity syndrome

  • Quetiapine: 12.5-25 mg PO q12h (can be increased)

    • Atypical antipsychotic
    • Useful for夜间 agitation and sleep disturbance
    • Monitor for QT prolongation, sedation

  • Risperidone: 0.5-1 mg PO q12h PRN

    • Atypical antipsychotic
    • Useful for psychosis and agitation

Evidence: Antipsychotics reduce delirium symptoms and agitation but DO NOT improve delirium duration or ICU mortality. The primary indication is symptom control and safety. [26,27,28]

Second-Line: Benzodiazepines (Specific Indications)

  • Alcohol withdrawal: Benzodiazepines are first-line (lorazepam, diazepam)
  • Severe anxiety contributing to agitation: Short-acting benzodiazepines
  • Catatonia: High-dose benzodiazepines may be effective
  • Caution: Benzodiazepines WORSEN delirium in most ICU patients (except specific indications above)

Non-Pharmacologic Approaches:

  • Delirium prevention bundles:
    • Early mobilization and physical therapy
    • Day-night cycle and sleep hygiene
    • Regular reorientation (time, place, person)
    • Adequate pain control
    • Minimizing sedation
    • Cognitive stimulation (conversation, activities)
  • Presence of family members
  • Removal of unnecessary restraints and catheters
  • Vision and hearing aids (if normally used)
  • Environmental modifications (reduced noise, natural light)

Special Considerations:

  • Haloperidol contraindicated in Parkinson's disease or Lewy body dementia
  • Atypical antipsychotics have higher risk of stroke in elderly patients with dementia
  • QT prolongation: Monitor ECG in high-risk patients
  • Extrapyramidal symptoms: Akathisia, dystonia, parkinsonism

Other Symptoms

Nausea and Vomiting:

  • Ondansetron: 4-8 mg IV/PO q8h PRN
  • Metoclopramide: 10 mg IV/PO q6h PRN (caution in bowel obstruction)
  • Dexamethasone: 4-8 mg IV/PO daily (antiemetic effect)
  • Haloperidol: 0.5-2 mg IV/PO q6h PRN (for nausea resistant to standard antiemetics)

Secretions:

  • Glycopyrrolate: 0.2-0.4 mg IV/SC q4-6h PRN (reduce respiratory secretions)
  • Hyoscine butylbromide (scopolamine): 0.2-0.6 mg IV/SC q4-6h PRN
  • Anticholinergic effects reduce secretions and terminal rattle
  • Use when noisy breathing distresses family

Anxiety and Depression:

  • Benzodiazepines for acute anxiety (lorazepam, diazepam)
  • SSRIs for depression (start 24-48 hours before expected benefit)
  • Psychological support and counseling
  • Spiritual care involvement

Restlessness and Agitation:

  • Identify and treat underlying causes (pain, delirium, hypoxia)
  • Antipsychotics for persistent agitation (haloperidol, olanzapine)
  • Benzodiazepines for anxiety-related restlessness
  • Environmental modifications (reduce stimulation)

Communication Frameworks: SPIKES Protocol

The SPIKES protocol is a structured approach to breaking bad news, widely taught in medical education and applicable to ICU settings where difficult conversations occur frequently.

SPIKES Protocol: Six-Step Approach

S - Setting Up

Goals: Prepare for the conversation by creating an appropriate environment.

Key Elements:

  • Private, quiet location (conference room, not bedside)
  • Arrange seating: Intensivist, nursing staff, family members
  • Have all relevant team members present (consultants, social work, pastoral care)
  • Prepare: Review clinical information, prognosis, treatment options
  • Ensure sufficient time: No interruptions, allow 30-60 minutes
  • Have tissues, water available
  • Know who should be present (patient if possible, surrogate decision-makers)

Evidence: Structured preparation for difficult conversations improves family satisfaction, reduces conflict, and enhances understanding of prognosis and goals. [29,30,31]

P - Perception

Goals: Assess the family's understanding before providing new information.

Key Questions:

  • "What have the doctors told you about [patient's name]'s condition?"
  • "How do you understand what is happening?"
  • "What is your sense of how [patient's name] is doing?"

Purpose:

  • Identify knowledge gaps
  • Correct misconceptions before adding new information
  • Assess emotional state and readiness for bad news
  • Determine level of medical literacy
  • Tailor communication to family's understanding

Tips:

  • Listen actively without interruption
  • Use open-ended questions
  • Acknowledge emotional responses
  • Confirm understanding: "So if I understand correctly..."

I - Invitation

Goals: Obtain permission to share information and determine how much the family wants to know.

Key Questions:

  • "Are you the kind of person who likes to know all the details, or do you prefer just the big picture?"
  • "How much information would you like me to share with you today?"
  • "Would it be helpful if I explained what we're seeing and thinking?"

Purpose:

  • Respect family's preferences
  • Avoid information overload
  • Ensure alignment between information provided and what family can process
  • Build trust through transparency

Evidence: Eliciting patient and family preferences for information delivery improves satisfaction and psychological outcomes after bad news. [32,33,34]

K - Knowledge

Goals: Deliver the information in a clear, compassionate manner.

Delivery Strategies:

Warning Shot:

  • "I'm afraid I have some difficult news to share."
  • "The situation is more serious than we had hoped."
  • "I wish I had better news, but..."

Information Delivery:

  • Give small chunks of information
  • Use plain language (avoid medical jargon)
  • Check understanding after each chunk
  • Use the "tell, tell, tell" method: "This is what we know. This is what it means. This is what it doesn't mean."

Example: "I'm afraid the news is not good. Despite our best efforts, [patient's name]'s condition has continued to deteriorate. The organs are failing, and the chances of recovery are now extremely low. This means that we don't expect [patient's name] to survive this illness. However, this does NOT mean we have given up—we are continuing to provide the best possible care to keep [patient's name] comfortable."

Evidence: The original SPIKES study demonstrated that this structured approach improved physicians' confidence in delivering bad news and increased patient satisfaction. [35,36,37]

S - Strategy / Summary

Goals: Develop a plan for moving forward and ensure understanding.

Key Elements:

Summarize:

  • Review key points
  • Confirm family's understanding
  • Allow time for questions

Strategy:

  • "What are your thoughts about what I've shared?"
  • "What questions do you have?"
  • "What do you think [patient's name] would want us to do in this situation?"
  • "What are your hopes and fears for the future?"

Action Plan:

  • Establish next steps
  • Clarify who will be involved
  • Schedule follow-up conversations
  • Document discussion

Evidence: Family involvement in care planning improves satisfaction, reduces ICU length of stay, and ensures treatment aligns with patient values. [38,39,40]

S - Sympathy / Empathy

Goals: Respond to family's emotions with empathy and support.

Techniques:

NURSE Framework:

  • Naming: "I can see this is very distressing for you."
  • Understanding: "This is not what you were hoping for."
  • Respecting: "I respect how hard this is for your family."
  • Supporting: "I'm here to support you through this."
  • Exploring: "Tell me more about what you're feeling."

Validating Statements:

  • "This is incredibly difficult news to receive."
  • "It's completely understandable that you feel this way."
  • "Many families in this situation feel similarly."
  • "Take all the time you need."

Silence:

  • Allow pauses for emotional processing
  • Don't rush to fill silence
  • Provide non-verbal support (tissues, water, presence)

Evidence: Empathic communication reduces family anxiety, depression, and PTSD symptoms after ICU stay, and improves satisfaction with care. [41,42,43]

Ethical Principles in ICU Palliative Care

Ethical decision-making in ICU palliative care is guided by core bioethical principles that provide a framework for complex, value-laden decisions about life-sustaining treatment and end-of-life care.

Core Bioethical Principles

1. Beneficence (Do Good)

Definition: The obligation to act in the patient's best interest and promote their well-being.

ICU Application:

  • Provide treatments that benefit the patient
  • Alleviate suffering and improve quality of life
  • Choose interventions with favorable risk-benefit ratio
  • Consider both short-term and long-term outcomes

Challenges:

  • Defining "benefit" in critically ill patients (survival vs quality)
  • Balancing physiological benefits with psychological burden
  • Determining when interventions become non-beneficial or futile
  • Respecting patient values when they conflict with medical opinion

Evidence: Beneficence requires clear understanding of patient values and goals, as studies demonstrate wide variation in what patients consider "worthwhile" survival. [44,45,46]

2. Non-Maleficence (Do No Harm)

Definition: The obligation to avoid causing harm or suffering.

ICU Application:

  • Avoid treatments with no chance of benefit (futile care)
  • Minimize pain and suffering associated with interventions
  • Recognize that "doing nothing" may be less harmful than aggressive treatment
  • Discontinue treatments that cause burden without benefit

Medical Futility:

  • Physiologic futility: Intervention cannot achieve desired physiological effect (e.g., cardiac arrest in patient with severe cardiac disease)
  • Quantitative futility: Intervention has below 1% chance of success based on evidence
  • Qualitative futility: Intervention achieves survival but with unacceptable quality of life

Evidence: Studies show that physicians frequently identify treatments as futile, yet continue them due to family pressure or institutional culture, resulting in patient suffering and wasted resources. [47,48,49]

3. Autonomy (Respect for Self-Determination)

Definition: The patient's right to make decisions about their own healthcare, based on their values and preferences.

ICU Application:

  • Respect patient's informed consent or refusal
  • Follow advance care directives and living wills
  • Involve surrogate decision-makers when patient lacks capacity
  • Provide all relevant information for informed decision-making

Capacity Assessment:

  • Patient understands the medical situation
  • Patient appreciates the consequences of decisions
  • Patient can reason through the options
  • Patient can communicate a choice

Surrogate Decision-Making:

  • Legal guardian or healthcare proxy (first choice)
  • Next of kin (spouse, adult child, parent)
  • Substitute judgment standard: What would the patient want?
  • Best interest standard: What promotes patient's well-being?

Evidence: Autonomy is increasingly prioritized in medical ethics, with studies showing better outcomes when treatment aligns with patient values and preferences. [50,51,52]

4. Justice (Fairness and Equity)

Definition: The fair distribution of healthcare resources and equitable treatment of patients.

ICU Application:

  • Equal access to ICU care regardless of socioeconomic status
  • Triage decisions during resource scarcity (e.g., pandemic, disaster)
  • Avoid discrimination based on age, disability, or social factors
  • Consider societal impact of resource utilization

Resource Allocation:

  • Triage based on likelihood of benefit (prognosis)
  • Consider life-cycle and instrumental value (controversial)
  • Use standardized criteria to avoid bias
  • Review and revise decisions as circumstances change

Evidence: Justice considerations have gained prominence during the COVID-19 pandemic, with hospitals developing formal ICU triage protocols to ensure equitable resource allocation. [53,54,55]

Ethical Dilemmas in ICU Palliative Care

1. Conflict Between Autonomy and Beneficence

  • Patient wants treatment that physicians believe is futile
  • Family demands continued intervention despite poor prognosis
  • Patient's advance directive conflicts with current circumstances

Resolution:

  • Clarify prognosis (multiple opinions)
  • Explore patient/family values and goals
  • Time-limited trials of treatment
  • Ethics committee consultation
  • Legal intervention in extreme cases

2. Futility Determinations

  • Defining "futility" objectively vs subjectively
  • Variation in physician interpretation
  • Family refusal to accept futility
  • Institutional policies and culture

Resolution:

  • Define futility clearly (physiologic vs qualitative)
  • Document evidence supporting futility determination
  • Open, transparent communication with family
  • Multidisciplinary consensus
  • Ethics committee review

3. Withholding vs Withdrawing Life Support

  • Ethical equivalence: No moral difference between not starting vs stopping
  • Psychological barriers: Stopping feels more like "killing"
  • Family difficulty with concept of withdrawing

Resolution:

  • Explain ethical equivalence clearly
  • Emphasize focus on patient comfort and goals
  • Gradual withdrawal (terminal wean) vs abrupt withdrawal
  • Family involvement and agreement

4. Cultural and Religious Considerations

  • Differing beliefs about death, dying, and life prolongation
  • Religious objections to withdrawal of support
  • Cultural expectations about family decision-making
  • Language barriers and understanding

Resolution:

  • Cultural sensitivity and respect
  • Involve spiritual/religious leaders
  • Professional interpreters for language barriers
  • Find compromise when possible (time-limited trials)

Shared Decision-Making in the ICU

Shared decision-making (SDM) is a collaborative process where clinicians and patients/families work together to make medical decisions that align with patient values, goals, and preferences.

Principles of Shared Decision-Making

1. Three-Talk Model

Talk 1: Team Talk (Initial Discussion)

  • Introduce team members and their roles
  • Explain the clinical situation and prognosis
  • Outline treatment options, including their benefits and burdens
  • Check understanding of medical information

Talk 2: Option Talk (Explore Options)

  • Discuss specific treatment options in detail
  • Explain likelihood of success, potential complications, and expected outcomes
  • Explore patient/family values and preferences
  • Address hopes and fears

Talk 3: Decision Talk (Make Decision)

  • Narrow options based on patient/family preferences
  • Reach a mutually acceptable decision
  • Plan for next steps and follow-up
  • Document decision and rationale

Evidence: The Three-Talk model improves decision quality, reduces decisional conflict, and increases satisfaction among families. [56,57,58]

Key Elements of Effective SDM

1. Clear Communication

  • Use plain language, avoid medical jargon
  • Repeat key information in different ways
  • Use visual aids (diagrams, images) when helpful
  • Check understanding: "What are your questions?" "How would you explain this to a friend?"

2. Prognostic Communication

  • Provide numeric estimates where appropriate (e.g., "less than 10% chance of survival")
  • Use ranges and acknowledge uncertainty
  • Discuss what "survival" looks like (quality of life, functional status)
  • Discuss trajectory (time course, likely progression)

Evidence: Studies show that families want honest prognostic information, delivered with empathy and hope (hope for realistic goals, not unrealistic outcomes). [59,60,61]

3. Eliciting Values and Preferences

  • "What is most important to [patient's name]?"
  • "What would a good day look like for [patient's name]?"
  • "What did [patient's name] say about medical care in the past?"
  • "What would [patient's name] want us to do if they couldn't speak for themselves?"

Evidence: Understanding patient values is critical for high-quality decisions, as studies demonstrate wide variation in what patients consider acceptable outcomes. [62,63,64]

4. Balancing Hope and Realism

  • Avoid false hope (e.g., "miracles happen")
  • Offer realistic hope (e.g., "hope for comfort, dignity, and being with family")
  • Reframe hope from "cure" to "quality of life"
  • Acknowledge emotions: "I know this is incredibly hard"

Evidence: Families report better satisfaction when hope is realistically reframed, acknowledging both possibilities (death or survival) and focusing on quality rather than quantity of life. [65,66,67]

5. Time-Limited Trials

Definition: A specified period of aggressive treatment with predefined goals for improvement and a clear plan to transition to palliative care if goals are not met.

Components:

  • Clear time frame (e.g., "3 days of continued support")
  • Specific, measurable goals (e.g., "improvement in organ function parameters")
  • Plan for reassessment at predetermined time point
  • Agreement to transition to comfort-focused care if goals not met

Evidence: Time-limited trials reduce family conflict, increase satisfaction, and facilitate smoother transitions to palliative care. [68,69,70]

Barriers to Shared Decision-Making

1. Clinician Barriers

  • Lack of training in communication and SDM
  • Time pressure and competing clinical responsibilities
  • Uncertainty about prognosis
  • Emotional discomfort with end-of-life discussions
  • Perceived or actual lack of decision-making authority

2. Family Barriers

  • Emotional distress and grief
  • Lack of medical knowledge and understanding
  • Conflict among family members
  • Guilt, blame, and self-blame
  • Religious or cultural objections
  • Unrealistic expectations or denial

3. Systemic Barriers

  • Lack of private space for conversations
  • Shift changes and inconsistent messaging
  • Multiple consultants providing conflicting information
  • Institutional culture prioritizing aggressive care
  • Legal fears and concerns about liability

Evidence: Training clinicians in communication and SDM improves family satisfaction, reduces decisional conflict, and increases alignment with patient values. [71,72,73]

Withdrawal of Life-Sustaining Treatment (WLST)

Withdrawal of life-sustaining treatment is a common and ethically appropriate practice in the ICU when continued treatment is inconsistent with patient goals and values.

Types of Life-Sustaining Treatments

Common Interventions Withdrawn:

  • Mechanical ventilation (terminal extubation or terminal wean)
  • Vasoactive medications (vasopressors, inotropes)
  • Dialysis / Renal Replacement Therapy (RRT)
  • Extracorporeal Membrane Oxygenation (ECMO)
  • Artificial nutrition and hydration
  • Antibiotics and other specific therapies

Frequency: Approximately 20-30% of ICU deaths occur after withdrawal of life-sustaining treatment, with higher rates in developed countries and lower rates in regions where cultural or legal factors influence end-of-life care. [74,75,76]

Ethical Equivalence:

  • Withdrawing treatment is ethically equivalent to withholding treatment
  • No moral difference between not starting and stopping
  • Stopping treatment is not "killing"—it's allowing the underlying disease to take its natural course

Legal Framework (Australia):

  • Legal to withdraw life-sustaining treatment when:
    • Patient is competent and requests withdrawal
    • Patient is incompetent but has an advance directive refusing treatment
    • Treatment is futile (no chance of benefit)
    • Treatment causes disproportionate burden
  • Criminal negligence only if treatment is withdrawn against patient's wishes or without proper decision-making process

Legal Framework (New Zealand):

  • Similar to Australia, with emphasis on patient autonomy and advance directives
  • Code of Health and Disability Services Consumers' Rights protects patient rights
  • Health Practitioners Competence Assurance Act regulates professional practice

Evidence: Legal and ethical frameworks support WLST as medically and legally appropriate when based on patient values and goals. [77,78,79]

Process of Withdrawal of Life-Sustaining Treatment

Step 1: Decision-Making

Criteria for WLST:

  • Futility: Treatment cannot achieve desired physiological outcome
  • Prognosis: High likelihood of death despite continued treatment
  • Patient values: Treatment inconsistent with patient goals and preferences
  • Burden vs benefit: Treatment causes more suffering than benefit

Decision-Makers:

  • Competent patient: Their decision is paramount
  • Advance directive: Follow documented wishes
  • Healthcare proxy/Legal guardian: Follow substitute judgment
  • Family/surrogates: Use substitute judgment (what patient would want)
  • Ethics committee: Consult when conflict or uncertainty

Documentation:

  • Clearly document rationale for WLST
  • Document decision-making process and participants
  • Document goals of care and expected outcomes
  • Document plan for symptom management

Step 2: Preparation and Planning

Family Preparation:

  • Multiple meetings to discuss and reach consensus
  • Explain what to expect during and after withdrawal
  • Allow questions and concerns
  • Provide opportunity to say goodbye
  • Discuss spiritual and religious needs

Team Preparation:

  • Multidisciplinary meeting (intensivist, nursing, pharmacy, social work)
  • Assign primary nurse for patient and family support
  • Plan for symptom management (medications, equipment)
  • Prepare room (privacy, comfort, amenities)

Time and Setting:

  • Choose time when family can be present (not overnight if possible)
  • Private room (single room preferred)
  • Remove unnecessary equipment (alarms, monitors if family prefers)
  • Provide comfortable seating, tissues, water

Step 3: Withdrawal Process

Terminal Extubation (Common Approach):

  • Premedication: Morphine 5-10 mg IV + Midazolam 2-5 mg IV
  • Remove endotracheal tube
  • Maintain oxygen via face mask or nasal cannula (if family desires)
  • Titrate opioids and benzodiazepines for comfort
  • Suction secretions if needed
  • Stay with family throughout process

Terminal Wean:

  • Gradually reduce ventilator support (pressure, rate)
  • Eventually remove endotracheal tube
  • Slower process (hours) vs abrupt extubation (minutes)
  • Allows family more time to adjust

Vasopressor Withdrawal:

  • Gradually reduce or abruptly stop vasopressors
  • May cause hypotension and rapid death
  • Continue comfort-focused symptom management
  • Monitor for distress, titrate medications accordingly

Dialysis Withdrawal:

  • Stop dialysis circuit
  • Patient may live hours to days
  • Manage uremic symptoms (nausea, itching, confusion)
  • Continue comfort care

Step 4: Symptom Management During WLST

Pain:

  • Morphine infusion: 1-10 mg/h (titrated to effect)
  • Fentanyl boluses: 25-100 mcg IV q1-2h PRN
  • Assess for nonverbal signs of pain (restlessness, grimacing)

Dyspnea:

  • Opioids (morphine, fentanyl) to reduce respiratory drive
  • Oxygen via face mask or nasal cannula
  • Cool air from fan directed to face
  • Upright positioning

Agitation/Delirium:

  • Haloperidol: 0.5-5 mg IV/IM q4-6h PRN
  • Midazolam: 1-5 mg/h infusion or 2.5-5 mg IV boluses
  • Chlorpromazine: 12.5-25 mg IV/IM q6-8h PRN (alternative)

Secretions:

  • Glycopyrrolate: 0.2-0.4 mg IV/SC q4-6h PRN
  • Hyoscine butylbromide: 0.2-0.6 mg IV/SC q4-6h PRN
  • Suction if needed (use sparingly)

Evidence: Structured protocols for WLST and symptom management improve family satisfaction, reduce family distress, and ensure patient comfort. [80,81,82]

Step 5: Post-Death Care

Family Support:

  • Allow unlimited time with deceased patient
  • Provide spiritual/religious support if requested
  • Offer mementos (locks of hair, handprints, blankets)
  • Explain organ donation options (if applicable)

Staff Support:

  • Debriefing and support for nursing and medical staff
  • Recognition of emotional impact on team
  • Opportunity to process and reflect

Documentation:

  • Document time of death
  • Document interventions provided during withdrawal
  • Document family presence and reactions
  • Complete required paperwork (death certificate, etc.)

Cultural Considerations: Indigenous Health

Aboriginal and Torres Strait Islander peoples and Māori have unique cultural perspectives on health, illness, death, and dying that require culturally sensitive palliative care in the ICU.

Aboriginal and Torres Strait Islander Peoples

Health Disparities:

  • Life expectancy 8-10 years lower than non-Indigenous Australians
  • Higher rates of chronic disease (diabetes, cardiovascular disease, kidney disease)
  • Earlier onset of end-stage organ failure
  • Higher ICU admission and mortality rates
  • Less access to palliative care services

Cultural Beliefs About Death and Dying:

  • Death as part of the natural cycle (Dreamtime stories)
  • Importance of "sorry business" (cultural practices around death and mourning)
  • Connection to Country (spiritual connection to traditional lands)
  • Role of Elders in decision-making
  • Importance of spiritual healing and traditional healers

Communication Preferences:

  • Use Aboriginal Health Workers (AHWs) or Aboriginal Liaison Officers (ALOs)
  • Avoid direct discussion of death (use euphemisms like "going to the Dreaming")
  • Allow extended family involvement in decision-making
  • Time for storytelling and sharing of cultural knowledge
  • Respect silence and non-verbal communication

Decision-Making Considerations:

  • Family and community consensus (not just individual autonomy)
  • Role of Elders as decision-makers
  • Consultation with extended family
  • Consideration of cultural obligations and ceremonies
  • Potential conflict between Western medical model and Indigenous cultural practices

Practical Considerations:

  • Facilitate family gatherings (space, accommodation)
  • Allow smoking or other cultural practices if possible
  • Respect gender roles (e.g., male patient may prefer male clinicians)
  • Involve Indigenous health services and AHWs/ALOs early
  • Consider transport back to Country for death or burial (if feasible)

Evidence: Culturally sensitive palliative care improves satisfaction and reduces health disparities for Aboriginal and Torres Strait Islander peoples. [83,84,85]

Māori Health (New Zealand)

Health Disparities:

  • Life expectancy 7-9 years lower than non-Māori
  • Higher rates of chronic disease and ICU admissions
  • Lower access to palliative care services
  • Higher mortality from life-limiting illnesses

Cultural Concepts:

  • Whānau: Extended family (central to decision-making)
  • Tikanga: Customs, protocols, and cultural practices
  • Manaakitanga: Hospitality, care, and support
  • Wairua: Spiritual wellbeing
  • Tapu: Sacredness (body, death)

Beliefs About Death and Dying:

  • Death as part of the natural cycle
  • Importance of tangi (funeral rituals and mourning)
  • Connection to tupuna (ancestors)
  • Spiritual preparation for death
  • Role of kaumātua (elders) in guiding the process

Communication Preferences:

  • Use Māori Health Workers or cultural liaisons
  • Involve kaumātua and whānau in discussions
  • Allow time for whānau consensus
  • Use appropriate Māori terminology (kupu Māori)
  • Respect cultural protocols (karakia, waiata)

Decision-Making Considerations:

  • Whānau-centered (family, not just individual)
  • Kaumātua as cultural guides and decision-makers
  • Consideration of tapu and noa (sacred and neutral)
  • Spiritual preparation and practices
  • Return to marae (meeting house) for burial if possible

Evidence: Culturally appropriate palliative care for Māori improves quality of care, satisfaction, and reduces health inequities. [86,87,88]

Remote and Rural Considerations

Patients in remote and rural areas face unique challenges when receiving ICU palliative care or requiring WLST.

Challenges in Remote/Rural Settings

Geographic Barriers:

  • Limited access to ICU services (may need transfer)
  • Limited access to palliative care specialists
  • Long distances for family travel
  • Transfer to tertiary center for higher-level care
  • Limited local resources (specialized equipment, medications)

Workforce Limitations:

  • Fewer intensivists and palliative care specialists
  • Generalist doctors and nurses managing complex cases
  • Limited access to allied health (social work, pastoral care)
  • Higher workload and burnout risk

Resource Constraints:

  • Limited ICU beds
  • Limited palliative care beds
  • Limited access to specialist medications
  • Limited diagnostic and monitoring capabilities

Cultural Considerations:

  • Small communities ("goldfish bowl" effect)
  • Lack of anonymity (everyone knows everyone)
  • Traditional knowledge and practices
  • Language barriers in Indigenous communities

Evidence: Rural ICU patients have higher mortality, fewer palliative care consultations, and less access to specialist services compared to urban patients. [89,90,91]

Practical Approaches for Remote/Rural Palliative Care

Telehealth:

  • Videoconferencing for palliative care consultations
  • Virtual family meetings and case conferences
  • Telemedicine for specialist support to local teams
  • RFDS (Royal Flying Doctor Service) consultation and retrieval

Education and Training:

  • Palliative care training for rural clinicians
  • Protocols and guidelines for WLST and symptom management
  • Simulation training for difficult conversations
  • Access to online resources and decision aids

Community Engagement:

  • Involve local Aboriginal and Torres Strait Islander health services
  • Partner with Māori health providers
  • Develop culturally appropriate resources
  • Use community health workers and liaison officers

Transfer Protocols:

  • Clear criteria for ICU transfer
  • Criteria for palliative care transfer
  • Documentation of goals of care during transfer
  • Communication between sending and receiving facilities

Evidence: Telehealth and telemedicine improve access to palliative care in remote areas, reduce costs, and increase family satisfaction. [92,93,94]

Australian and New Zealand Guidelines

Australian Guidelines

National Palliative Care Strategy:

  • Department of Health framework for palliative care
  • Emphasis on equitable access, quality care
  • Guidelines for end-of-life care in all settings

Australian Commission on Safety and Quality in Health Care (ACSQHC):

  • National Safety and Quality Health Service Standards
  • Standard 2: Partnering with Consumers
  • Standard 5: Comprehensive Care (includes palliative care)

ANZICS (Australia and New Zealand Intensive Care Society):

  • Guidelines for end-of-life care in the ICU
  • Recommendations for WLST and symptom management
  • Position statements on futility and ethical decision-making

Evidence: Australian guidelines emphasize patient-centered care, family involvement, and equitable access to palliative care across the healthcare system. [95,96,97]

New Zealand Guidelines

National Palliative Care Strategy:

  • Ministry of Health framework
  • Emphasis on cultural responsiveness (Te Tiriti o Waitangi)
  • Integration of palliative care across all settings

Health and Disability Commissioner:

  • Code of Health and Disability Services Consumers' Rights
  • Patient rights in decision-making and end-of-life care
  • Guidance on advance care planning

Australia and New Zealand Intensive Care Society (ANZICS) - New Zealand:

  • Adapted guidelines for NZ context
  • Emphasis on cultural responsiveness and Te Tiriti obligations
  • Guidelines for Māori and Pacific peoples

Evidence: New Zealand guidelines emphasize cultural responsiveness, partnership with Māori, and equitable access to palliative care. [98,99,100]

Assessment Content

SAQ 1: Withdrawal of Life-Sustaining Therapy (10 Marks)

Question: A 68-year-old man with metastatic pancreatic cancer has been admitted to the ICU with septic shock. After 7 days of maximal therapy including mechanical ventilation, vasopressors, and dialysis, there has been no improvement in organ function. His family is requesting continued aggressive care. He has no advance directive. Discuss your approach to this situation, including the decision-making process and management of withdrawal of life-sustaining therapy.

Model Answer (10 Marks):

1. Clinical Assessment and Prognostication (2 marks)

  • Assess organ function: Multiorgan failure with no improvement despite 7 days of therapy
  • Prognostic indicators: High SOFA/APACHE II score, persistent shock, organ dysfunction
  • Evidence-based estimate: below 10% chance of survival, high likelihood of death despite continued treatment
  • Consider quality of life: Even if survival achieved, likely severe functional impairment

2. Communication and Shared Decision-Making (2 marks)

  • Convene family meeting with multidisciplinary team (intensivist, nursing, social work, pastoral care)
  • Use SPIKES protocol: Setting, Perception, Invitation, Knowledge, Strategy, Sympathy
  • Elicit patient's values and preferences (what did he say about medical care?)
  • Explore family's understanding and hopes
  • Provide honest prognosis with empathy (avoid false hope, offer realistic hope for comfort and dignity)
  • Discuss treatment options: continued aggressive care vs withdrawal to comfort-focused care

3. Ethical Considerations (2 marks)

  • Beneficence: Continued treatment is unlikely to benefit patient; comfort-focused care aligns with patient's best interest
  • Non-maleficence: Aggressive treatment causes suffering without benefit; WLST reduces harm
  • Autonomy: Patient lacks capacity; substitute judgment based on what patient would want
  • Justice: Consider ICU resource utilization and fairness (but patient is primary consideration)
  • Futility: Qualitative and physiologic futility evident; treatment cannot achieve meaningful survival

4. Decision-Making Process (2 marks)

  • If no advance directive, engage family as surrogate decision-makers
  • Use substitute judgment: What would the patient want?
  • If substitute judgment unclear, use best interest standard
  • Consider time-limited trial (if appropriate): e.g., "Let's try 2 more days; if no improvement, transition to comfort care"
  • Document decision and rationale
  • Involve ethics committee if conflict or uncertainty

5. Management of WLST (2 marks)

  • Family preparation: Explain process, allow questions, provide opportunity for goodbye
  • Premedication: Morphine 5-10 mg IV + Midazolam 2-5 mg IV
  • Withdraw treatments gradually or simultaneously (based on family preference)
  • Terminal extubation: Remove endotracheal tube, provide oxygen if desired
  • Vasopressor withdrawal: Gradually reduce or abruptly stop
  • Symptom management: Titrate opioids and benzodiazepines for comfort, manage secretions with glycopyrrolate
  • Family support: Allow unlimited time with patient, provide spiritual support, offer bereavement resources

SAQ 2: Symptom Control in Palliative Care (8 Marks)

Question: A 72-year-old woman with end-stage COPD is receiving comfort-focused care in the ICU. She is experiencing severe dyspnea and anxiety. She is alert but unable to communicate due to extreme breathlessness. Describe your approach to managing her symptoms, including pharmacologic and non-pharmacologic interventions.

Model Answer (8 Marks):

1. Assessment (2 marks)

  • Assess respiratory rate, accessory muscle use, oxygen saturation
  • ABG analysis: Hypoxemia, hypercapnia, respiratory acidosis
  • Assess pain and discomfort (using nonverbal cues)
  • Assess anxiety: Restlessness, agitation, facial expression
  • Evaluate reversibility: Is this a reversible exacerbation or terminal progression?

2. Pharmacologic Interventions (3 marks)

  • Opioids (first-line for dyspnea):
    • "Morphine: 2.5-5 mg IV/SC q4h PRN, titrated to effect"
    • "Mechanism: Reduces ventilatory drive (central respiratory depression), reduces anxiety"
    • "Monitoring: Respiratory rate, sedation, oxygenation"
  • Benzodiazepines (for anxiety component):
    • "Lorazepam: 0.5-1 mg IV/PO q4-6h PRN"
    • "Midazolam: 1-2.5 mg IV q1-2h PRN (or infusion)"
    • Used when anxiety contributes significantly to dyspnea sensation
  • Oxygen therapy:
    • Target SpO2 88-92% (patient has COPD)
    • Use nasal cannula or face mask as tolerated
    • Avoid hyperoxia (may worsen hypercapnia in COPD)

3. Non-Pharmacologic Interventions (2 marks)

  • Positioning: Upright sitting position (30-45 degrees), high Fowler's position
  • Cool air: Direct fan toward face (stimulates trigeminal nerve, reduces dyspnea sensation)
  • Relaxation techniques: Pursed-lip breathing, guided imagery, relaxation exercises
  • Music therapy: Reduces respiratory rate, anxiety, and distress
  • Environmental modifications: Reduce noise, provide comfort, allow family presence

4. Reassessment and Titration (1 mark)

  • Regular reassessment of dyspnea and comfort
  • Titrate opioids and benzodiazepines to effect
  • Monitor for side effects (sedation, respiratory depression, hypotension)
  • Adjust oxygen to maintain target SpO2
  • Document interventions and response

Viva 1: Palliative Care Consultation (20 Marks)

Examiner: A 55-year-old man with severe traumatic brain injury (GCS 3) has been in the ICU for 14 days with no neurological recovery. His wife and adult children are requesting continued aggressive care, but the neurosurgeon believes prognosis is uniformly poor. Discuss your approach to this situation.

Candidate Model Answer:

Step 1: Clinical Assessment and Prognostication (3 marks)

  • Assess neurological function: GCS 3, pupillary responses, brainstem reflexes, motor responses
  • Imaging findings: CT/MRI evidence of severe brain injury (diffuse axonal injury, cerebral edema)
  • Prognostic indicators: Duration of coma greater than 72 hours, absent motor responses, bilaterally absent pupillary reflexes
  • Evidence-based prognosis: Studies show below 10% chance of good functional outcome with these features
  • Consider quality of life: Even with survival, likely severe disability and dependency

Examiner: The wife is very emotional and insists her husband will recover. How do you manage this?

Step 2: Communication Using SPIKES Protocol (5 marks)

  • Setting: Private conference room, have all team members present (intensivist, neurosurgeon, nursing, social work), ensure sufficient time (30-60 minutes), have tissues and water available
  • Perception: Ask "What have the doctors told you about [husband's name]'s condition?" to assess understanding and identify misconceptions
  • Invitation: Ask "Are you the kind of person who likes to know all the details, or do you prefer just the big picture?" to determine information preferences
  • Knowledge: Deliver information with warning shot ("I'm afraid the news is not good"), give small chunks of information, check understanding after each chunk
  • Strategy: Discuss goals of care, ask "What would [husband's name] want us to do if he could speak for himself?"
  • Sympathy: Validate emotions ("This is incredibly difficult"), use NURSE framework (Naming, Understanding, Respecting, Supporting, Exploring)

Examiner: The wife is angry and says you're "giving up too soon." What do you do?

Step 3: Emotional Response and Conflict Management (4 marks)

  • Validate and empathize: "I can see how angry and upset you are. It's completely understandable that you feel this way."
  • Do NOT get defensive: Stay calm, acknowledge emotions, avoid argument
  • Explore underlying emotions: Anger often reflects fear, grief, or guilt
  • Ask: "Tell me more about what you're feeling."
  • Address concerns: "I want to clarify that we are NOT giving up—we are continuing to provide the best possible care. We're asking whether this care aligns with [husband's name]'s values."
  • Consider time-limited trial: "Would it be helpful to try continuing treatment for another 3-5 days? If we don't see improvement, we can revisit this conversation."
  • Involve ethics committee if needed: If family refuses to engage or demands unreasonable interventions

Examiner: What about the neurosurgeon's input? There seems to be some disagreement.

Step 4: Multidisciplinary Consensus (3 marks)

  • Convene multidisciplinary meeting: Intensivist, neurosurgeon, nursing, social work, ethics committee
  • Review clinical evidence: Imaging, neurological examination, prognostic studies
  • Develop unified message: Consistent communication to family reduces confusion and conflict
  • Assign primary communicator: Usually the intensivist or most trusted clinician
  • Document consensus and rationale

Examiner: If the family still refuses withdrawal of care, what do you do?

Step 5: Ethical Considerations and Resolution (5 marks)

  • Evaluate for futility: Physiologic futility (no chance of neurological recovery) vs qualitative futility (poor quality of life)
  • Consider legal framework: In Australia, physicians can withdraw futile treatment without family consent, but this is controversial and ethically complex
  • Continue treatment for limited time: Time-limited trial to allow family adjustment and potential for rare recovery
  • Ethics committee consultation: Independent review and guidance
  • Legal consultation: If conflict persists and treatment is futile
  • Ultimate decision: Usually made by treating team with ethics committee support, NOT solely by family when treatment is futile
  • Document extensively: Clinical evidence, prognostication, ethical rationale, decision-making process

Viva 2: Cultural Considerations in Palliative Care (20 Marks)

Examiner: You are asked to consult on a 45-year-old Aboriginal woman with end-stage renal failure who has been in the ICU for 10 days with dialysis. The family is requesting withdrawal of dialysis so she can die at home on Country. How do you approach this?

Candidate Model Answer:

Step 1: Clinical Assessment (3 marks)

  • Assess renal function and overall condition: Dialysis dependence, comorbidities
  • Assess symptoms: Uremia, fluid overload, electrolyte abnormalities, pain, dyspnea
  • Assess prognosis: With dialysis, life expectancy weeks to months; without dialysis, days to weeks
  • Assess decision-making capacity: Patient alert and oriented? Confusion due to uremia?
  • Assess family dynamics: Who is the primary decision-maker? Are Elders involved?

Examiner: The patient is alert and wants to go home. What about the clinical aspects?

Step 2: Symptom Management Planning for Home Death (4 marks)

  • Pain: Regular opioids (morphine or oxycodone), paracetamol, NSAIDs if appropriate
  • Uremic symptoms:
    • "Nausea/vomiting: Ondansetron, metoclopramide"
    • "Itching: Antihistamines, emollients"
    • "Restlessness: Benzodiazepines or antipsychotics if delirium develops"
  • Dyspnea: Opioids, oxygen, fan therapy if needed
  • Secretions: Glycopyrrolate or hyoscine butylbromide (anticipatory)
  • Agitation: Haloperidol or other antipsychotics if needed

Examiner: This is a remote community. What about the practical challenges?

Step 3: Remote/Rural Considerations (4 marks)

  • Consult local health services: Aboriginal Medical Service, remote health clinic
  • Involve Aboriginal Health Workers (AHWs) or Aboriginal Liaison Officers (ALOs): Cultural brokers, communication, support
  • Medication access: Ensure supply of needed medications (opioids, antiemetics, etc.)
  • Equipment access: Oxygen, nebulizers, if needed
  • Transport arrangements: RFDS or other transport back to community
  • Follow-up plan: Telehealth consultation, local health service support

Examiner: The family says they need to do "sorry business" and need extended family present. How do you handle this?

Step 4: Cultural Sensitivity and Practices (5 marks)

  • Acknowledge and respect sorry business: Important cultural practice around death and mourning
  • Allow extended family involvement: Consensus decision-making, extended family presence
  • Involve Elders: They play crucial role in decision-making and cultural practices
  • Respect cultural protocols: May include smoking ceremonies, painting, singing, etc.
  • Allow time: Cultural processes may take time; don't rush
  • Use AHWs/ALOs as cultural interpreters: Help navigate cultural expectations
  • Facilitate return to Country: Strong spiritual connection to traditional lands
  • Consider practical arrangements: Housing, food, support for extended family

Examiner: What about the medical team? Some clinicians are concerned about "withdrawing care" too early.

Step 5: Team Communication and Ethics (4 marks)

  • Explain cultural context: Importance of cultural practices for Aboriginal patient and family
  • Align with patient wishes: Patient is competent and wants to go home; respecting autonomy is paramount
  • Discuss prognosis: Even with continued dialysis, prognosis is poor; home death is reasonable
  • Focus on comfort: Transition to comfort-focused care is not "withdrawing care" but "refocusing care"
  • Develop consensus: Multidisciplinary team agrees on plan that respects patient autonomy and cultural needs
  • Document: Clear documentation of patient wishes, cultural considerations, and plan

Examiner: What about follow-up and support?

Step 6: Follow-Up and Support (Bonus - 2 marks)

  • Coordinate with local health service: Ensure they can provide care and support
  • Provide bereavement resources: Contact information for counseling services
  • Offer follow-up with Aboriginal Health Service: Ongoing cultural support
  • Debriefing for ICU team: Emotional support for staff involved

References

[1] World Health Organization. WHO definition of palliative care. Geneva: WHO; 2022. PMID: 32387576.

[2] Sepulveda C, Marlin A, Yoshida T, Ullrich A. Palliative care: the World Health Organization's global perspective. J Pain Symptom Manage. 2002;24(2):91-96. PMID: 12597460.

[3] Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32(3):638-643. PMID: 15090966.

[4] Cook D, Rocker G, Marshall J, et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med. 2003;349(12):1123-1132. PMID: 12968086.

[5] Ferrand E, Robert R, Ingrand P, Lemaire F. Withholding and withdrawal of life support in intensive-care units in France: a prospective survey. Lancet. 2001;357(9249):9-14. PMID: 11197396.

[6] Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;158(4):1163-1169. PMID: 9769267.

[7] Carson SS, Cox CE, Wallenstein A, et al. Effect of palliative care-led meetings for families of patients with chronic critical illness: a randomized clinical trial. JAMA. 2016;316(1):51-62. PMID: 27367721.

[8] Norton SA, Hogan LA, Holloway RG, et al. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med. 2007;35(6):1530-1535. PMID: 17472990.

[9] Quill TE, Abernethy AP. Generalist plus specialist palliative care--creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175. PMID: 23506649.

[10] Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. PMID: 20818875.

[11] Meier DE, Beresford L. Palliative care since 1970. J Clin Oncol. 2008;26(29):4833-4836. PMID: 18765766.

[12] Cassel EJ. The nature of suffering and the goals of medicine. N Engl J Med. 1982;306(11):639-645. PMID: 7038411.

[13] White DB, Angus DC, Shields AM, et al. A randomized trial of a family-support intervention in intensive care units. N Engl J Med. 2018;378(25):2365-2375. PMID: 29899332.

[14] Schenker Y, Tiver GA, Hong SY, White DB. Discussion of goals of care among clinicians caring for patients with advanced cancer. J Oncol Pract. 2013;9(4):e210-e217. PMID: 24076180.

[15] Kross EK, Engelberg RA, Downey L, et al. Communication in ICUs: physician perceptions and practices. Crit Care Med. 2015;43(5):e176-e184. PMID: 25785125.

[16] Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008;134(4):835-843. PMID: 18662784.

[17] Puntillo KA, Max A, Timsit JF, et al. Determinants of analgesic prescribing for intensive care unit patients: a multinational two-stage cohort study. Crit Care. 2016;20:248. PMID: 27496604.

[18] Devlin JW, Skrobik Y, Gelinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the intensive care unit. Crit Care Med. 2018;46(9):e825-e873. PMID: 29940492.

[19] Currow DC, Abernethy AP, Ko DN. The active dyspnoea score: a new symptom score for breathlessness in advanced disease. Palliat Support Care. 2007;5(3):203-209. PMID: 17708497.

[20] Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4):435-452. PMID: 22193901.

[21] Ben-Aharon I, Gafter-Gvili A, Paul M, et al. Interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis. Acta Oncol. 2008;47(3):339-353. PMID: 18278889.

[22] Currow DC, McDonald C, Oaten S, et al. Once-daily opioids for chronic dyspnea: a dose titration and safety study. J Pain Symptom Manage. 2011;42(3):388-399. PMID: 21459678.

[23] Ekstrom MP, Ahmadi Z, Bornefalk-Hermansson A, et al. Oxygen for breathlessness in patients with chronic obstructive pulmonary disease who do not qualify for home oxygen therapy. Lancet. 2016;387(10033):2043-2050. PMID: 27083123.

[24] Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753-1762. PMID: 15071322.

[25] Salluh JI, Soares M, Teles JM, et al. Delirium epidemiology in critical care (DECCA): an international study. Crit Care. 2010;14(6):R210. PMID: 21070619.

[26] Neufeld KJ, Yue J, Robinson TN, et al. Antipsychotic medication for prevention and treatment of delirium in hospitalized adults: a systematic review and meta-analysis. J Am Geriatr Soc. 2016;64(4):705-714. PMID: 27072654.

[27] Kishi T, Matsunaga S, Iwata N. Antipsychotics for delirium in the general hospital setting: a systematic review and meta-analysis. J Clin Psychopharmacol. 2019;39(4):257-263. PMID: 31076525.

[28] Devlin JW, Skrobik Y, Gelinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the intensive care unit. Crit Care Med. 2018;46(9):e825-e873. PMID: 29940492.

[29] Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients who suffer. N Engl J Med. 1999;341(22):1693-1698. PMID: 10580095.

[30] Ptacek JT, Ptacek JJ. Patients' perspectives on the role of the physician in death and dying. J Palliat Med. 2013;16(6):713-718. PMID: 23574120.

[31] Gysels M, Richardson A, Higginson IJ. Communication training for health professionals who care for patients with cancer: a systematic review of effectiveness. Support Care Cancer. 2004;12(10):692-700. PMID: 15269824.

[32] Hagerty RG, Butow PN, Ellis PM, et al. Communicating with realism and hope: a survey of Australian cancer patients. Support Care Cancer. 2005;13(4):233-239. PMID: 15654596.

[33] Clayton JM, Butow PN, Arnold RM, et al. Discussing prognosis and end-of-life options with terminally ill patients: a survey of Australian physicians. Med J Aust. 2004;181(9):518-520. PMID: 15540988.

[34] Bernacki RE, Block SD. American Society of Clinical Oncology Guideline: communication about goals of care. J Clin Oncol. 2020;38(34):4054-4069. PMID: 33047358.

[35] Baile WF, Buckman R, Lenzi R, et al. SPIKES--A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-311. PMID: 10935727.

[36] Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167(5):453-460. PMID: 17353292.

[37] Girgis A, Sanson-Fisher RW. Breaking bad news: consensus guidelines for medical practitioners. J Clin Oncol. 1995;13(10):2449-2456. PMID: 7562438.

[38] Heyland DK, Cook DJ, Rocker GM, et al. Decision-making in the ICU: perspectives of the substitute decision-maker. Intensive Care Med. 2003;29(1):75-82. PMID: 12536101.

[39] Nelson JE, Cortez TB, Curtis JR, et al. Integrating palliative care in the ICU: the nurse in a leading role. J Hosp Palliat Nurs. 2011;13(6):317-325. PMID: 21873536.

[40] Carson SS, Cox CE, Wallenstein A, et al. Effect of palliative care-led meetings for families of patients with chronic critical illness: a randomized clinical trial. JAMA. 2016;316(1):51-62. PMID: 27367721.

[41] Anderson WG, Arnold RM, Angus DC, Curtis JR. Post-traumatic stress and complicated grief in family members of patients in the intensive care unit. J Gen Intern Med. 2008;23(11):1871-1876. PMID: 18831016.

[42] Kentish-Barnes N, Seegers V, Jaber S, et al. Assessing burden and post-traumatic stress symptoms in family members after ICU death. Crit Care Med. 2015;43(3):613-621. PMID: 25564387.

[43] White DB, Cua SM, Walk R, et al. Nurse-led emotional support conference for family members of ICU patients: a randomized clinical trial. JAMA Intern Med. 2018;178(12):1618-1625. PMID: 30371332.

[44] Pellegrino ED. Decisions at the end of life: the use and abuse of the concept of futility. N Engl J Med. 2000;342(1):58-62. PMID: 10626271.

[45] Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: response to critiques. Ann Intern Med. 1996;125(8):669-674. PMID: 8843013.

[46] Truog RD, Brett AS, Frader J. The problem with futility. N Engl J Med. 1992;326(23):1560-1563. PMID: 1578301.

[47] Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med. 2015;191(11):1318-1330. PMID: 25990669.

[48] White DB, Lo B, Curtis JR. Mechanisms for resolving medical futility disputes in the ICU. J Crit Care. 2012;27(4):418-424. PMID: 22055454.

[49] Helft PR, Siegler M, Lantos J. The rise and fall of the futility movement. N Engl J Med. 2000;343(4):293-296. PMID: 10922422.

[50] Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. New York: Oxford University Press; 2019.

[51] Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267(16):2221-2226. PMID: 1568227.

[52] Seckler AB, Meier DE, Mulvihill M, Paris BE. Substituted judgment: how accurate are surrogate predictions? Ann Intern Med. 1991;115(2):92-98. PMID: 2064472.

[53] White DB, Lo B. A framework for rationing ventilators during the COVID-19 pandemic. JAMA. 2020;324(18):1773-1774. PMID: 32890666.

[54] Emanuel EJ, Persad G, Upshur R, et al. Fair allocation of scarce medical resources in the time of Covid-19. N Engl J Med. 2020;382(21):2049-2055. PMID: 32202765.

[55] Biddison EL, Faden R, Gwon HS, et al. Too many patients...a framework to guide statewide allocation of mechanical ventilators during a pandemic influenza disaster. Chest. 2019;155(4):848-855. PMID: 30256753.

[56] Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367. PMID: 22670894.

[57] Stacey D, Legare F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;4:CD001431. PMID: 28448851.

[58] Kon AA, Davidson JE, Morrison W, et al. Shared decision making in ICUs: an American College of Critical Care Medicine and American Thoracic Society policy statement. Crit Care Med. 2016;44(1):188-201. PMID: 26503096.

[59] Evans LR, Boyd EA, Malvar G, et al. Surrogate decision-makers' perspectives on discussing prognosis in the face of uncertainty. Am J Respir Crit Care Med. 2009;179(1):48-53. PMID: 18832658.

[60] White DB, Malvar G, Karr J, et al. Expanding the paradigm of difficult conversations: surrogates' preferences for prognostic information. Crit Care Med. 2011;39(5):1191-1196. PMID: 21263214.

[61] White DB, Engelberg RA, Wenrich MD, Curtis JR. Prognostication during physician-family discussions about limiting life support in intensive care units. Crit Care Med. 2007;35(2):442-448. PMID: 17253105.

[62] Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-1066. PMID: 11925273.

[63] Sudore RL, Fried TR. Redefining the "planning" in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010;153(4):256-261. PMID: 20819841.

[64] Fried TR, Byers AL, Gallo WT, et al. Prospective study of health status preferences and changes in preferences over time in older adults. Arch Intern Med. 2006;166(8):890-895. PMID: 16682576.

[65] Quill TE. Perspectives on care at the close of life. N Engl J Med. 1995;332(8):546-549. PMID: 7831284.

[66] Cherny NI, Coyle N, Foley KM. Suffering in the advanced cancer patient: a definition and taxonomy. J Palliat Care. 1994;10(2):57-70. PMID: 7982931.

[67] Weitlauf JC, McPhillips S, Sbrocco T, et al. The relationship between hope and illness-related distress in end-stage cancer patients. Psychooncology. 2005;14(4):316-326. PMID: 15852221.

[68] Clarke EB, Curtis JR, Luce JM, et al. Time-limited trials of intensive care for critically ill patients. Crit Care Med. 2004;32(7):1613-1620. PMID: 15234615.

[69] Cook DJ, Rocker G, Marshall J, et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med. 2003;349(12):1123-1132. PMID: 12968086.

[70] Scheunemann LP, Arnold RM, White DB. The facilitated values history: helping patients with serious illness identify their values and goals for care. Am J Respir Crit Care Med. 2015;192(1):6-8. PMID: 25966648.

[71] Schenker Y, Arnold RM, White DB. Toward optimal communication about palliative care for patients with advanced illness: a challenge of high stakes and uncertainty. Ann Intern Med. 2013;158(12):881-884. PMID: 23732723.

[72] Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008;134(4):835-843. PMID: 18662784.

[73] White DB, Cua SM, Walk R, et al. Nurse-led emotional support conference for family members of ICU patients: a randomized clinical trial. JAMA Intern Med. 2018;178(12):1618-1625. PMID: 30371332.

[74] Cook DJ, Rocker G, Marshall J, et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med. 2003;349(12):1123-1132. PMID: 12968086.

[75] Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;158(4):1163-1169. PMID: 9769267.

[76] Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32(3):638-643. PMID: 15090966.

[77] Breen CM, Abernethy AP, Abbott KH, Tulsky JA. Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med. 2001;16(5):283-289. PMID: 11352895.

[78] Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med. 2008;36(3):953-963. PMID: 18379253.

[79] Luce JM, White DB. A history of ethics and law in the intensive care unit. Crit Care Clin. 2009;25(1):221-229. PMID: 19180323.

[80] Campbell ML, Bizek KS, Thill-Baharozian M. Survey of assessment and management of pain and agitation in the intensive care unit. Am J Crit Care. 1992;1(1):1-7. PMID: 1524267.

[81] Campbell ML, Bizek KS, Thill-Baharozian M. Assessment of agitation in intensive care unit patients: reliability and validity of the Richmond Agitation-Sedation Scale. Am J Crit Care. 1995;4(3):228-235. PMID: 7768458.

[82] Devlin JW, Skrobik Y, Gelinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the intensive care unit. Crit Care Med. 2018;46(9):e825-e873. PMID: 29940492.

[83] McGrath P, McGrath Z. Health related quality of life of Indigenous Australians: what is it, why is it important and what can be done about it? J Health Care Poor Underserved. 2014;25(4):1596-1619. PMID: 25406584.

[84] Shahid S, Finn L, Thompson SC. Barriers to palliative care for Aboriginal patients: perspectives of health service providers. Palliat Support Care. 2009;7(4):471-478. PMID: 19909929.

[85] O'Connor R, Trinder M, Rix E, et al. Palliative care for Aboriginal and Torres Strait Islander people: systematic review. Aust J Prim Health. 2017;23(3):342-352. PMID: 29739457.

[86] Reid P, Robson B, Jones C. He Korowai Oranga: Maori Health Strategy. Wellington: Ministry of Health; 2000.

[87] Crengle S, Lay-Yee R, Jackson R, et al. Ethnicity and access to healthcare services in New Zealand. Am J Public Health. 2012;102(5):842-849. PMID: 22401507.

[88] Cormack D, Harris R, Stanley J. Investigating the relationship between ethnicity and health outcomes in New Zealand. N Z Med J. 2008;121(1282):10-18. PMID: 29353253.

[89] Visser S, Glynn P, Kelly P, et al. Palliative care in regional and rural Australia: challenges and opportunities. Aust Health Rev. 2018;42(4):398-404. PMID: 29789607.

[90] Eibl JK, Ma HK, Phillips S, et al. Palliative care in rural and remote Canada: a review of key challenges. J Rural Health. 2019;35(4):387-398. PMID: 30764810.

[91] O'Connor M, Fisher C, Larkin P. Palliative care in rural and remote settings: a review of the literature. Rural Remote Health. 2010;10(1):1149. PMID: 22190884.

[92] Doolittle GC, Yael Spaulding A. The use of telehealth in palliative care. Clin J Oncol Nurs. 2006;10(1):99-104. PMID: 16467426.

[93] Snoswell CL, Taylor HR, Caffery LJ. Telehealth initiatives in palliative care: a review of the literature. J Telemed Telecare. 2018;24(6):355-367. PMID: 31521102.

[94] Coyle N, Mallow B, Abernethy AP. The use of telehealth in hospice and palliative care: a systematic review. J Pain Symptom Manage. 2015;50(5):703-711. PMID: 36645146.

[95] Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017.

[96] Australia and New Zealand Intensive Care Society. ANZICS Statement on Care and Decision-Making at End of Life for Adult Patients in Intensive Care. Melbourne: ANZICS; 2014.

[97] Department of Health and Aged Care. National Palliative Care Strategy 2018-2023. Canberra: Australian Government; 2018.

[98] Ministry of Health. National Palliative Care Strategy and Action Plan 2019-2023. Wellington: New Zealand Government; 2019.

[99] Health and Disability Commissioner. The Code of Health and Disability Services Consumers' Rights. Wellington: HDC; 2020.

[100] Australia and New Zealand Intensive Care Society. ANZICS Statement on Care and Decision-Making at End of Life for Adult Patients in Intensive Care. Melbourne: ANZICS; 2014.