End-of-life care in icu

Surgical approach (if applicable)

• Not an operation: no surgical approach. End-of-life care in ICU is a multidisciplinary process (ICU, parent team, palliative care, nursing, chaplaincy, AHPs).
• If organ donation after circulatory death (DCD) is planned, surgical teams may be involved after death is confirmed (retrieval).
  • Decision to withdraw treatment must be made independently of donation discussions; separate teams where possible.

Anaesthetic management (if applicable)

• Not a theatre anaesthetic. Key ICU competencies overlap with anaesthesia: analgesia/sedation, airway/ventilation changes, management of distress, and family communication.
• Type of anaesthesia: N/A (ICU sedation/analgesia rather than GA/regional).
• Airway: often ETT/tracheostomy in situ; may be extubated or left in place depending on plan and symptom burden.
• Duration: variable (minutes to days) after withdrawal depending on physiology and which supports are stopped.
• Pain/distress: potentially high if not proactively managed (dyspnoea, agitation, secretions). Aim is comfort, not hastening death.

Definitions and scope

• End-of-life care in ICU: care of a patient who is dying or likely to die soon, focusing on comfort, dignity, and support for family.
• Withholding vs withdrawing life-sustaining treatment (LST): ethically and legally equivalent in UK; both require best-interests decision-making.
• LST examples: invasive ventilation, NIV, vasopressors/inotropes, RRT, ECMO, antibiotics, artificial nutrition/hydration (CANH), CPR.
• DNACPR: decision about CPR only; does not equal ‘do not treat’. Must be integrated into an overall treatment escalation plan (TEP).

Ethical framework (FRCA core)

• Principles: respect for autonomy, beneficence, non-maleficence, justice.
• Double effect: symptom-relieving drugs (opioids/benzodiazepines) are acceptable if intention is relief and doses are proportionate, even if life-shortening is a foreseeable but unintended effect.
• Futility: avoid using as a standalone label; discuss in terms of likelihood of achieving patient-valued goals and burdens vs benefits.
• Best interests: includes medical, emotional, social, and spiritual welfare; consider patient’s values, beliefs, and previously expressed wishes.

Legal framework (UK): key points for ICU end-of-life

• Mental Capacity Act 2005 (England/Wales): presume capacity; support decision-making; unwise decisions ≠ lack of capacity; act in best interests; least restrictive option.
• If patient has capacity: they can refuse any treatment (including life-sustaining) even if this results in death; must be informed and voluntary.
• Advance Decision to Refuse Treatment (ADRT): legally binding if valid and applicable; for life-sustaining treatment must be written, signed, witnessed, and include statement that it applies even if life is at risk.
• Lasting Power of Attorney (LPA) for Health & Welfare: can make decisions if patient lacks capacity; must act in best interests; authority depends on scope and registration.
• DNACPR: must follow national guidance; involve patient if possible; if not, consult those close to patient unless impracticable or would cause harm (harm = more than distress).
• Assisted dying remains illegal in UK; symptom control is legal when proportionate and intended to relieve suffering.
• Scotland differs (Adults with Incapacity (Scotland) Act 2000); NI has separate legislation—know local policy if working there.

Decision-making process in ICU

• Recognise dying: triggers include irreversible multi-organ failure, refractory shock/hypoxaemia, catastrophic neurological injury, or treatment burdens outweighing benefits.
• Clarify goals of care: survival with acceptable quality of life vs time-limited trial vs comfort-focused care.
• Capacity assessment: decision-specific, time-specific; document reasoning.
• Best-interests meeting (MDT): include ICU consultant, bedside nurse, parent team, palliative care (if available), and consider family views of patient’s wishes.
• Communicate clearly with family: explain uncertainty, what will happen, and what symptoms will be treated; avoid jargon and false precision.
• Document: decision, rationale, participants, patient’s wishes/values, agreed plan (what will stop/continue), DNACPR/TEP, and review plan.
• Disagreement: seek second consultant opinion, ethics/legal advice, mediation; if unresolved and time allows, Court of Protection may be required for serious disputes.

Practical withdrawal/withholding of life-sustaining treatment (LST)

• General principles: plan ahead; ensure comfort first; anticipate symptoms; assign roles; ensure privacy; offer family presence and support.
• What may be stopped: vasopressors/inotropes, ventilation/NIV, RRT, ECMO, antibiotics, blood products, invasive monitoring, routine bloods, non-essential procedures.
• What usually continues: analgesia, anxiolysis/sedation for comfort, oxygen if it relieves dyspnoea, secretion management, mouth/eye care, pressure area care, family support.
• Ventilation withdrawal options:
  • Terminal extubation: remove ETT once comfortable; may reduce distressing interventions; manage secretions and stridor risk.
  • Terminal wean: reduce ventilatory support while leaving ETT in situ; sometimes preferred if secretions/airway obstruction likely.
• Vasopressor withdrawal: usually stop infusions (or stepwise reduction) once comfort drugs established; anticipate rapid deterioration.
• RRT withdrawal: stop filtration/dialysis; manage dyspnoea, agitation, pruritus, and fluid overload symptomatically.
• Nutrition/hydration: decisions individualised; CANH may be burdensome; provide mouth care and treat thirst/dryness; consider clinically assisted hydration only if it improves comfort.

Symptom control in the dying ICU patient

• Common symptoms: dyspnoea/air hunger, pain, agitation/delirium, anxiety, noisy respiratory secretions, nausea/vomiting, seizures, stridor.
• Opioids (e.g., morphine, fentanyl, alfentanil): treat pain and dyspnoea; titrate to comfort; consider renal/hepatic failure when choosing agent and dose.
  • Renal failure: avoid morphine accumulation; consider fentanyl/alfentanil.
• Benzodiazepines (e.g., midazolam): treat anxiety, agitation, dyspnoea-related distress; useful for terminal agitation and seizures.
• Antipsychotics (e.g., haloperidol/levomepromazine): consider for delirium-related agitation; avoid if prominent Parkinsonism/QT issues; tailor to local policy.
• Secretions (‘death rattle’): repositioning, reduce fluids if appropriate, gentle suction only if visible/accessible; antimuscarinics (glycopyrronium/hyoscine butylbromide/hyoscine hydrobromide) may help.
• Refractory symptoms: consider palliative sedation (proportionate sedation for intolerable suffering refractory to standard measures) with senior review and clear documentation.
• Neuromuscular blockade: do not use to treat distress; if patient is paralysed, ensure adequate sedation/analgesia before stopping paralysis and before withdrawal of ventilation.

Communication and family support (ICU-specific)

• Prepare: quiet room, sit down, introductions, check understanding, ask what matters to the patient, explore values and acceptable outcomes.
• Explain the plan: what will be stopped, what will continue, what symptoms may occur, how they will be treated, and what dying may look like.
• Language: avoid ‘withdraw care’ (say ‘withdraw treatment’); avoid euphemisms that confuse; be honest about uncertainty.
• Family presence: offer to be present at bedside; explain alarms/monitors; consider stopping non-essential monitoring to reduce distress.
• Spiritual/cultural needs: ask proactively; involve chaplaincy/cultural liaison; consider organ donation discussions appropriately and separately.
• After death: explain verification/certification processes, viewing, bereavement support, and practical next steps.

After-death care and documentation

• Confirm expected death and DNACPR status; ensure clear documentation of time and circumstances of death per local policy.
• Verification of death: follow local policy (usually trained clinician); note absence of circulation/respiration and fixed pupils; consider longer observation if hypothermia/drug effects.
• Medical Certificate of Cause of Death (MCCD): complete accurately; refer to coroner/Procurator Fiscal when required (e.g., unexpected, trauma, perioperative, poisoning, industrial disease).
• Tissue/organ donation: follow national referral pathways; ensure separation from withdrawal decision-making; document discussions and consent.