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End-of-life care can be improved

Researchers have evaluated improvements in the end-of-life care in intensive care units (ICU) and have shared their findings in a special supplement to Critical Care Medicine, the journal of the Society of Critical Care Medicine. The supplement is dedicated entirely to end-of-life care in the critical care setting.

"Improving the quality of care received by critically ill and dying patients in the ICU remains an ongoing challenge," explains guest co-editor J. Randall Curtis, M.D., M.P.H., professor of medicine at the University of Washington in Seattle. "Over the past five years there have been encouraging signs of improvement in end-of-life care in the ICU. Interventions have been developed, evaluated, and published to improve the care that patients and their families receive relating to the end of life in the ICU."

Approximately one in five deaths in the United States now occurs in the ICU or shortly after receiving intensive care. The ICU is likely to remain an important setting for end-of-life care because of the severity of illness in these patients and because many families and patients with chronic, life-limiting diseases will opt for a trial of intensive care.

Critical care researchers are taking the lessons learned from previous observational studies and using them to develop and test generalizable interventions that improve the quality of ICU end-of-life care. The Critical Care Medicine supplement includes 20 articles evaluating end-of-life issues, including palliative care in the ICU, attitudes toward withholding and withdrawing life support, ethical and legal issues, quality indicators, communications between physicians and nurses, interventions for children at the end of life, and promising future directions.

"We believe this supplement documents the tremendous progress that has been made in the past decade and represents the state of the art for assessing and improving end-of-life care in the ICU," comments gue st co-editor Mitchell Levy, M.D., professor of medicine at Brown University School of Medicine in Providence, R.I.

Quality End-of-Life Palliative Care
A paper by Ira Byock, M.D., a professor at Dartmouth Medical School and director of palliative medicine at Dartmouth Hitchcock Medical Center in Lebanon, N.H., describes recent developments in the integration of palliative and critical care.

Palliative and end-of-life care in the ICU is an appropriate and under-developed area for quality assessment and improvement, according to Richard Mularski, M.D., M.S.H.S., from the Veterans Affairs Greater Los Angeles Healthcare System. Dr. Mularski and a number of the other contributors to this supplement combined forces to develop an article that provides a practical framework for examining processes of care that might be quality measures. This article proposes 18 candidate quality measures that could be implemented in ICUs tomorrow. Dr. Mularski and colleagues suggest that further work also is needed to demonstrate such measures are valid and reliable.

End-of-Life Interventions
Considering that 20% of deaths in the United States occur in ICUs and that the quality of life in an ICU at the end of life often is rated as poor, improving the quality of end-of-life care in this setting is seen as an important endeavor. In an article on measuring quality improvement, Dr. Curtis and co-author Ruth A. Engelberg, Ph.D., from the University of Washington in Seattle, examine data supporting potential process and outcome measures that could be used to evaluate the success of interventions designed to improve end-of-life care in the ICU.

Dr. Levy notes that this supplement documents a need for additional research and quality improvement in order to realize the potential for improving the care delivered to critically ill patients at the end of life as well as the care provided to their families.

The supplement resulted from the c onference, "Improving the Quality of End-of-Life Care in the ICU: Interventions that Work," which was funded by the Robert Wood Johnson Foundation and hosted by the Society of Critical Care Medicine on February 17-19, 2006, in Miami, Fla.

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