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General Hospital Psychiatry 32 (2010) 433 442

End-of-life communication in the intensive care unit

Tomer T. Levin, M.B., B.S.a,,1 , Beatriz Moreno, M.A.b ,
William Silvester, M.B., B.S.c , David W. Kissane, M.D.a
a
Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
b
Fuenfria Hospital, 28470 Cercedilla, Madrid, Spain
c
Intensive Care Unit, Austin Hospital, Heidelberg, Victoria 3084, Australia
Received 9 March 2010; accepted 22 April 2010

Abstract

Objective: Because one in five Americans die in the intensive care unit (ICU), the potential role of palliative care is considerable. End-of-life
(EOL) communication is essential for the implementation of ICU palliative care. The objective of this review was to summarize current
research and recommendations for ICU EOL communication.
Design: For this qualitative, critical review, we searched PubMed, Embase, Cochrane, Ovid Medline, Cinahl and Psychinfo databases for
ICU EOL communication clinical trials, systematic reviews, consensus statements and expert opinions. We also hand searched pertinent
bibliographies and cross-referenced known EOL ICU communication researchers.
Results: Family-centered communication is a key component of implementing EOL ICU palliative care. The main forum for this is the
family meeting, which is an essential platform for implementing shared decision making, e.g., transitioning from curative to EOL palliative
goals of care. Better communication can improve patient outcomes such as reducing psychological trauma symptoms, depression and
anxiety; shortening ICU length of stay; and improving the quality of death and dying. Communication strategies for EOL discussions focus
on addressing family emotions empathically and discussing death and dying in an open and meaningful way. Central to this is viewing ICU
EOL palliative care and withdrawal of life-extending treatment as predictable and not an unexpected emergency.
Conclusions: Because the ICU is now a well-established site for death, ICU physicians should be trained with EOL communication skills so
as to facilitate palliative care more hospitably in this challenging setting. Patient/family outcomes are important ways of measuring the quality
of ICU palliative care and EOL communication.
2010 Elsevier Inc. All rights reserved.

Keywords: Communication skills training; Intensive care unit; End-of-life communication; Family communication; Palliative care; Death and dying

1. Introduction to be incongruent with the lack of hospitality shown to dying

Because approximately 22% of all deaths in the United
States occur during or after an intensive care unit (ICU)
admission [1], the potential role for palliative care commu-
nication is considerable. For example, the need for clinician
family communication about withholding or withdrawing
life-supporting therapies is the norm when a person dies in
the ICU, rather than the exception [26]. Nevertheless, a
palliative care philosophy towards dying is often perceived
Work performed at Memorial Sloan-Kettering Cancer Center.
Corresponding author. Tel.: +1 646 888 0021; fax: +1 212 888 2356.
E-mail address: levint@mskcc.org (T.T. Levin).
1
Tomer Levin's research is supported by a grant from the Martell
Foundation. No other financial support is disclosed.
0163-8343/$ see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.genhosppsych.2010.04.007
patients and their families, the impersonal technology and
the action-oriented ICU ethos [79].
Difficulties with ICU EOL communication are well
documented. Fifty-four percent of family members may have
a poor understanding of the patient's diagnosis, treatment and
prognosis; comprehension is particularly poor when physi-
cianfamily meetings last for less than 10 min [10]. A recent
study demonstrated that physicians tended to discuss EOL life-
sustaining treatment in a scripted, depersonalized and
procedure-focused manner, while surrogate decision makers
showed a poor integration of the medical dilemma that was the
goal of the decision-making discussion [11].
Another study showed that 40% of family members of
ICU patients retrospectively perceived that conflict had
occurred with ICU staff and 31% cited unprofessional
434 T.T. Levin et al. / General Hospital Psychiatry 32 (2010) 433442
behavior [12]. Examples included the physicians saying that
another patient needed the dying patient's bed, talking to a
sister-in-law who was a nurse while ignoring the primary
caregiver and having a do-not-resuscitate (DNR) discussion
at the bedside of a ventilated patient where the family
members were uncertain whether he could hear or not. Curtis
et al. [13] described frequent missed communication
opportunities in EOL family meetings, such as addressing
family emotions, affirming nonabandonment of the family
and discussing palliative care or ethics. Even clear, signed
advance directives and well-intentioned, competent physi-
cians do not mitigate the intrinsic complexity of EOL
communication [14] and the potential to cause iatrogenic
emotional harm [15].
This concise review aims to consider barriers to better
ICU EOL communication, approaches to counteracting these
barriers and evidence that better communication and
communication skills training might improve patient out-
comes. This is followed by a practical overview of EOL ICU
communication strategies.
1.1. Family-centric ICU EOL communication
The first step in implementing EOL palliative care is
usually family communication-reorienting goals of care from
hope of cure to palliation [16,17]. Delirium and use of
sedatives and analgesia result in the majority of critically ill
patients unable to make their own treatment decisions, even
after extubation [18,19]. The family therefore links the
patient to the ICU team. American College of Critical Care
consensus statements support the importance of family-
centered EOL communication [20,21].
One problem in this regard is that doctorfamily
communication is not taught in most medical schools or
critical care programs. Another problem is that there are
considerable barriers to better ICU family communication,
which is multifaceted rather than linear, and these are
considered below.
2. Barriers to better ICU EOL communication
2.1. Emotional barriers to EOL ICU communication
ICU physicians must be able to deal effectively with
strong and chaotic emotions, as well as promote consensus
among family and staff. When emotions, communication or
deciding what is best for the patient cannot be managed
within the ICU or the hospital (ethics committees, psychi-
atric consultations), external court intervention becomes
necessary (e.g., Quinlan, Cruzan and Schiavo cases) with
dramatic and long-lasting consequences [2225].
There are many inter-related reasons for high emotions in
the ICU. The blurred boundary between curative and
palliative goals of care is vulnerable to misperception and
disagreement [12,17,26,27]. In fact, the ICU admission is
often initiated as a therapeutic trial. Only when it fails are
curative goals of care reassessed [21]. Conflicting values,
culture, religion and prognostic challenges can amplify
emotions [17,2831]. Some 73% of family members of ICU
patients have significant levels of anxiety; 35% have
depression symptoms [32]. Distress therefore is a predictable
feature of the ICU family meeting.
A core strategy for managing overwhelming family
emotions is to respond empathically, but in one study of
51 ICU EOL family meetings, there were no empathic
responses at all in one third of these meetings [33]. Empathic
statements are significantly associated with greater satisfac-
tion with ICU care [33,34]. Conversely, lack of empathy
increases patient dissatisfaction and the malpractice risk
[35]. Patients who perceive their physicians as reassuring
and willing to discuss feelings at time of cancer diagnosis
report less anxiety 1 year later [36].
Empathy is not necessarily an innate quality. Empathic
strategies can be taught in communication training programs
[3740]. Larson and Yao [41] even propose a model for
teaching empathy based on principles of acting. Table 1 lists
common empathic communication techniques, both verbal
and nonverbal, used in teaching ICU clinicians at Memorial
Sloan Kettering Cancer Center's Comskil Lab [42].
Nonverbal empathic expressions (e.g., posture) predict
patient satisfaction independently of their assessment of the
physician's technical expertise [43]. Powerful empathic
skills include an awareness of another's discomfort and
suffering [44] and recognition of the human stories that
accompany illness [45].
Empathy and emotional engagement lie at the heart of
trust [4648]. Without trust, the ICU physician has no
foundation for EOL communication and decision making
with families. Why should a family believe that the best
course of action is to discontinue life-extending treatments if
Table 1
Eight empathic strategies for responding to emotions in ICU EOL
communication [42]
Strategies Suggested dialogues and notes
1. Normalizing/validating It is normal to be upset at such
a difficult moment
Your anger is understandable
2. Name or acknowledge You seem sad
the emotion I can see that you are upset
3. Gesture or touch Offering tissues, a drink or gentle
touch (if culturally appropriate)
may promote empathy or trust.
4. Encourage expression Tell me more about how you
are feeling
5. Paraphrase and repeat back If I understand you correctly, you are
angry because the oncologist said that
chemotherapy could be restarted after
the ICU had treated the pneumonia.
6. Apologize I am sorry that things have not worked
out as we might have wished
7. Praise/affirm adaptive coping This takes great courage
8. Silence Silence reflects listening, acknowledging
and sharing suffering.
 T.T. Levin et al. / General Hospital Psychiatry 32 (2010) 433442
they lack trust in their physicians or the institution that stands
behind them?
Family satisfaction can be used as a barometer of
communication and, indeed, communication successes and
failures generate more gratitude and complaints than any
other aspect of care [12,49]. Satisfaction is associated with
being given the opportunity to ask questions; articulate
personal values; express painful emotions; and discuss
concerns, feelings or guilt [50,51]. The Family-Satisfac-
tion-in-the-Intensive-Care Unit survey differentiates be-
tween satisfaction with care and satisfaction with decision
making [52,53]. It also correlates highly with the quality of
ICU dying and death [5457].
2.2. Prognostic barriers to ICU EOL communication:
anticipating death vs. death as an unexpected emergency
Approximately 90% of ICU deaths occur after decisions
to forgo or limit treatment [2,3,5,58]. Thus, the need to talk
about EOL goals of care and decision making is predictable
in the vast majority of patients who die in the ICU. Viewing
death as unpredictable turns it into an emergency. Anticipa-
tion allows for setting standards of care, education of staff
and mobilization of resources. There is a large movement
advocating standard protocols for withdrawal of life-
extending treatments, which are available online [16,59].
Similarly, Nelson et al. [60] have developed a family
meeting toolbox to help ICU staff plan for the meeting,
assist the family to set their agenda and document outcomes,
including a template with checkboxes to satisfy billing or
quality improvement requirements. The toolbox also con-
tains a prognostic schema to determine the likelihood of an
ICU admission longer than 5 days. Other prognostic systems
can also be used to generate more objective data supporting
the likelihood of death [61], albeit not without controversy
[62]. Prognostic information should be presented so as to aid
comprehension and retention, such as citing naturalistic
frequencies rather than probabilities [63]. To illustrate, it is
easier to understand when a clinician says that, in a group of
100 similar patients, 80 will die and 20 will be alive at
discharge, rather than saying there is a 20% survival to
discharge rate.
In summary, the more predictable the death, the easier it is
to plan and devote resources to its management. A key
element of this is communicating the anticipated prognosis
to the family. The often cited recommendation of a routine
family meeting within 72 h of ICU admission [64] is
somewhat dated because many deaths occur within this
timeframe the goal of a family meeting within 24 h of
admission seems more clinically pertinent.
2.3. Ethical barriers to ICU EOL communication
It is essential that ICU physicians appreciate the ethical
principles underlying ICU EOL communication. For in-
stance, clinicians must appreciate the importance of
respecting and maximizing patient autonomy, even when
435
the patient is incapacitated or ventilated and cannot verbally
express his or her wishes. Thus, decision making should be
patient centered, reflecting palliative care principles
[16,17,59,65].
One way that this is done is via substituted judgment. This
is used when a patient is incapacitated and has not left written
EOL advance directives to guide treatment; the surrogate
decision-maker is supposed to make medical decisions as if
she/he was in the patient's shoes [66]. To illustrate, when a
surrogate states that he could not imagine life without the
patient and declines withdrawal of life-extending care, this is
not substituted decision making. This is an example of a
decision based on the surrogate's own values. Substituted
judgment is saying, My Dad always said that everyone's time
comes and he would be ready for that moment, because here
the son is imagining what he might say if he was his father.
Another ethical principle is making decisions in the
patient's best interests. This is determined by considering the
patient's condition, prognosis, the benefits/burdens of
treatment options and the patient's prior views. Making
decisions based on knowing what the patient might have
wanted is preferable to making a decision based on the
perceived best interests of that person.
Making an EOL decision based on the need for an ICU
bed by another sick person reflects the principle of
distributive justice or resource allocation and this should
be avoided [67].
2.4. Barriers to joint decision making
Joint decision making also informs ICU EOL communi-
cation. This collaborative process involves educating and
reflecting on the patient's illness/prognosis, the benefits and
burdens of the treatment alternatives and the patient's values
and beliefs. Shared decision making has been associated
with a higher family satisfaction with communication [68].
American, European and Australian critical care societies
advocate this approach [69,70].
Shared decision making can be more difficult within the
ICU, where families do not have a preexisting relationship
with critical care physicians. Furthermore, many patients
have not discussed their wishes with their families and, even
when their wishes are known, family members often prove
ambivalent about planning for the dying process, even when
carrying out the patient's wishes. The physician needs to be
sensitive to the not uncommon circumstance of families who
cannot bear the burden of a shared decision to withdraw
treatment. In such cases, it is appropriate for the clinician to
bear responsibility for the medical decision. This is
supported by studies on patient preferences. For example,
one study of patients with a terminal diagnosis found that
52% would prefer shared decision making, 34% would
prefer to make their own decisions and 15% would defer to
their physicians. However, if they lacked capacity, 39%
would defer to their physicians [71]. This highlights the
importance of the personal qualities of physicians to make
436 T.T. Levin et al. / General Hospital Psychiatry 32 (2010) 433442

ethically appropriate and wise decisions [72]. A physician's very late in the dying trajectory, often on the day of death
knowledge and prior experience in treating similar EOL [79]. This delay may reflect physician discomfort or
cases are invaluable in guiding the family. avoidance with this discussion. Low health literacy is
Part of the process of shared decision making is education another barrier and researchers such as Volandes et al. [80]
and provision of medical information, but one study found suggest that a narrative description of comfort care or
that 35% of surrogates did not understand the physician's resuscitation is inadequate. Visual images of palliative care
explanation about the diagnosis and care options [73]. In or CPR may be more helpful in aiding understanding [80].
another, surrogates perceived the communication from the
physician to be insufficient [74], highlighting the difficulty 2.6. Physician unconscious barriers to EOL communication
of processing medical data at a time of crisis and anticipatory
The physician's unconscious reaction to EOL communi-
grief. Difficulty comprehending medical data at times of
cation can also present a barrier to communication. The
crisis suggests that communication skills training techniques
physician is unaware of these subtle emotional undertones,
such as checking family's understanding of the illness and
although they might be quite apparent to others. For
treatments and frequent summarizing are helpful [75]. An
example, a physician may think, There is nothing that I
educational brochure about what to expect from the dying
can offer this patient; feel a failure; and experience sadness.
process is also a well-established approach [76].
The nurse may wonder why the physician has not yet met
EOL decision making should not be hasty, nor is it
with the family.
appropriate to unilaterally withdraw treatment in the midst of
Delaying EOL conversations, communicating euphemis-
family protest. At the same time, futile treatment is not in the
tically (discussed below) or giving overly optimistic
patient's best interests. One strategy to find the balance
prognoses [15,81,82] may all be symptoms of the physi-
between clinical realism and family optimism is to propose a
cian's unconscious emotional reaction to the clinical
time-limited, empirical trial of treatment, with an agreement
interaction. Kelly et al. [83] provide a thoughtful overview
that, if there is no improvement in clinical parameters,
of how transference, countertransference and boundaries
treatment goals will be revised with a view to withdrawing
interact with EOL ethics. For instance, less experienced
futile life-extending treatments [77].
physicians may be more likely to agree with physician-
Stuttering withdrawal of life-extending treatment, as a
assisted suicide, pointing to a skill deficit influencing
consequence of avoidant EOL communication, is undesir-
decisions when they have difficulty tolerating helplessness
able. A recent study, however, paradoxically reported higher
[83]. Kelly et al. [84] elegantly demonstrated how
family satisfaction when the withdrawal of life-extending
physicians' unconscious attitudes may influence the desire
care took time. Here, the prolonged ICU admission was seen
to hasten death: physicians' subjective perception of reduced
to facilitate more certainty in decision making [8]. Ideally,
patient optimism and more emotional suffering (as well as
better EOL communication should replace the need for
less training in counseling) were factors predicting agree-
tempered withdrawal of treatment as a vehicle for accepting
ment with hastened death, a far cry from the objective factors
the inevitability of death. Communication should also aim to
that we would prefer to see considered in these deliberations.
prepare the family for bereavement [76]. The bottom line is
The concept of demoralization by Kissane et al. [85] is
that all parties should be certain that the decision is
another example of a factor that might be unwittingly
reasonable, given the circumstances.
influencing EOL decision making. Might a demoralized
physician be unconsciously more willing to push for
2.5. Do-not-resuscitate directives as a barrier to withdrawal of life-extending care?
ICU EOL communication Although emotional and organizational support for ICU
physicians is an American College of Critical Care
Semantics and choice of words are important in
consensus recommendation [21], addressing unconscious
communication. The term DNR, for example, may have
attitudes in communication skills training can be challeng-
authoritarian connotations, focusing on the negative, on
ing. Certainly, the more meaning and personal satisfaction a
what will not be provided. It does not reflect, in itself,
physician gains from his or her work, the greater the potential
palliative goals of care. A relatively new synonym is allow
for personal growth [86,87].
natural death (AND), which is used alongside DNR in
New York State's Medical-Orders-for-Life-Sustaining 2.7. Patients too sick for the ICU: EOL triaging by
Treatment (MOLST) program [78]. The advantage of ICU physicians
using the term AND directives is that it facilitates
discussion of the palliative goals of care in the EOL Patients triaged and deemed too sick to benefit from ICU
discussion. AND emphasizes a natural death; by admission invariably forego life-sustaining therapy. How-
extrapolation, cardiopulmonary resuscitation (CPR) is ever, these cases often display communication deficits such
incongruent with this palliative goal. as less discussion with patients/families or even rejection
Is the AND/DNR discussion poorly implemented? There over the phone, without an ICU physician actually seeing the
is evidence that AND/DNR directives are often implemented patient [8890]. Anecdotally, EOL communication is a
 T.T. Levin et al. / General Hospital Psychiatry 32 (2010) 433442
source of frustration for critical care physicians on triage
duty who are asked to evaluate dying patients, prima facie,
because the primary physician has avoided discussing EOL
goals of care. There is relatively little research to guide
this interaction.
2.8. Can communication skills training improve
patient outcomes?
Critical care training might change significantly if there
were convincing data demonstrating better patient/
family/ institutional outcomes as a result of communi-
cation skills training [91].
To illustrate, consider the traumatic effect of an ICU death
on next-of-kin as an outcome of communication training.
Ninety days after an ICU death, significant posttraumatic
stress symptoms are seen in 50% of next-of-kin, but when
the next-of-kin actually participated in EOL decisions, this
number jumps to 81.8% [74]. A recent New England
Journal of Medicine publication reported on a prospective
randomized controlled trial in 22 French ICUs using an
intervention that consisted of five printed objectives for the
EOL conference, presented to the physician before the
meeting, and a family brochure about what to expect from
the dying process [76]. Ninety days postmortem, the Impact
of Events scale was lower in the intervention group (P=.02),
indicating that 45% of the intervention group and 69% of the
control group were at risk for posttraumatic stress disorder.
Anxiety and depression were also lower (11 vs. 17, P=.004)
[76]. Limitations aside [40], this study suggests that better
communication through the ICU dying phase may reduce
next-of-kin grief burden.
Another interventional approach is to address institutional
processes of ICU palliative care. This is sometimes referred
to as the way that we do things around here [92] or the
hidden curriculum that attempts to preserve status quo.
Curtis et al.'s multifaceted intervention consists of clinician
education, local champions, academic detailing, feedback to
clinicians and system support [59]. Consecutive patients who
died in the ICU were identified pre- (n=253) and post-
intervention (n=337). Nurse-assessed quality of death and
dying showed significant improvement (Pb.01), but not
family-assessed quality of death and dying. The nurse's
assessment may provide valuable insight into the quality of
the death, as nurses spend the most time with dying ICU
patients and their families. There was also a significant
reduction in ICU length of stay before death (pre-
intervention, 3.9 days; post-intervention, 3.1days; Pb.01).
This intervention did not target pure communication.
Curtis et al. suggest that improving family ratings may
require interventions that have more direct contact with
family members, i.e., communication skills training
interventions.
Regarding economic patient outcomes, an Archives of
Internal Medicine study [93] found that only 31% of patients
with advanced cancer reported EOL discussions with their
437
oncologists. These patients' health care costs in the last week
of life were 36% less than those patients who had not
discussed EOL care. Survival was identical in both groups
[93]. This supports the rationale for communication being
the first step in a palliative care decision-making cascade.
A recent meta-analysis found that better communication
was associated with a 19% better adherence to treatment and
physicians who underwent communication skills training
achieved 1.62% better odds of adherence. Adherence to
medications has particular parallels with ICU EOL commu-
nication, including empathy; education; establishing a
clinicianpatient/family team; shared decision making;
discussion of benefits, risks and barriers/confounding
agendas [94].
EOL discussions do not make patients more depressed,
but they do reduce the rates of ventilation, resuscitation, ICU
admission and promote greater hospice enrollment [95].
Aggressive EOL care is associated with worse patient quality
of life and more depression among the bereaved [95].
Roter, a communication expert, in a three-arm random-
ized controlled study, demonstrated that 8 h of training in
either problem solving or addressing emotions significantly
improved problem defining and handling emotions, without
making consultations longer [96]. This, and the variety of
interventional studies above, emphasizes that multiple
strategies may be helpful in improving patient outcomes
from organizational, to educational, to purer communication
skills training approaches.
2.9. Talking openly about death and dying
Many communication clashes in the ICU occur because
clinicians and families are not, sometimes literally and
sometimes metaphorically, speaking the same language [97].
Families who report that clinicians give them mixed
messages in the ICU are significantly more likely to have
symptoms of anxiety and depression [98]. Phrases such as
the cancer is advancing (advancement is usually positive),
salvage chemotherapy (salvaging and recycling are good),
prognosis is guarded (stiff upper lip), if your heart
stopped beating (heart is treated as an isolated component
failure) are euphemisms that reflect avoidance of talking
directly about dying. When physicians are more confident
using words such as death and dying rather than euphe-
misms, the conversation is more authentic; communication
skills training can be used to practice integrating the words
death and dying into EOL conversations [42].
2.10. Interdisciplinary and spiritual
communication strategies
Discrepant perceptions about EOL care between doctors
and nurses are well described and often a source of
frustration, especially when nurses conclude before the
physician that the patient is unlikely to survive [99101].
Implementing spiritual care, an important component of
quality EOL care and another marker for family satisfaction
438 T.T. Levin et al. / General Hospital Psychiatry 32 (2010) 433442
in ICU [102,103], requires a high degree of interdisciplinary
communication. It should be individualized and culturally
sensitive, aiming to make the final moments gentler, more
personal and consistent with the patient's lived values [104].
Broadening involvement in the dying process has the
advantage of de-medicalizing death, placing responsibility
on society at large. Here death is viewed from the palliative
perspective as a natural consequence of living rather than as
a medical failure. This perspective can be enormously
liberating to the ICU clinician. The American College of
Critical Care's guidelines even recommend allowing pets
into the ICU to facilitate the goal of a more family-oriented
death [20].
2.11. Specific strategies for ICU EOL communication
Table 2 contains a communication algorithm for ICU
EOL family meetings, based on the communication skills
training approach of the Comskil Laboratory at Memorial
Sloan Kettering Cancer Center. It is not dissimilar to other
expert recommendations [26,105108]).
First and foremost, the algorithm emphasizes the
importance of addressing emotions empathically. Emotional
expression by the family is a cue that requires the clinician's
response [109], before moving ahead with EOL decision
making/problem solving. However, even in the absence of a
cue, it is appropriate to empathize with the patient's and
family's difficult plight. It is difficult to build trust or
promote rational decision making without first discussing
emotions. Listening is one effective technique for addressing
emotions. One study found that ICU physicians spoke for
70% and families for 30% of the time during family
meetings, but satisfaction with quality of care was associated
with more opportunity to speak [110]. A private location for
these intimate discussions is an important element in
facilitating trust, and the absence of such a room is associated
with greater family anxiety [98]. Thus, elements of the
setting facilitate the empathic tone.
Another communication skills training emphasis is on
discussing death and dying fruitfully. Gathering information
about death and dying preferences is a task that most ICU
physicians find uncomfortable. One strategy is simply to ask
directly. Especially in the setting of chronic illness, the
patient may have already articulated these wishes and
families are grateful to reflect on these further:
Physician: Did your father ever discuss the prospect of death
and dying?
Family: He said that he was ready to go! He said he had lived
a full life and that he did not want to linger [tears].
Education is a useful follow-up if the meaning of
palliative care is not entirely appreciated. Thus,
Physician: What is your understanding of comfort care?
[Physician listens carefully to family's understanding of these
terms so that misperceptions can be corrected]
Table 2
A guide for the ICU EOL family conference [42]
1. Pre-conference ICU team meeting
2. Introductions. Collaboratively set agenda
3. Assess family perception of illness, likely outcomes and treatment goals
a. Correct misperceptions, educate about illness/prognosis.
b. Rule: respond to emotions evoked by the discussion.
4. Gather specific information about death and dying preferences by one or
more of the following methods:
a. Ask directly about patient's prior thoughts regarding dying, EOL goals
of care and DNR/AND directives, or
b. Ask about past experiences with death and dying in the family, what
went well, what could be improved on and how these experiences
might guide ICU EOL goals of care and AND/DNR decisions, or
c. Substituted judgment: If the patient lacks decisional capacity, the family
can be asked, Who the patient is as a person? and If the patient could
speak to us right now, how might s/he guide us in our decision-making?
Note: Use the words death and dying. Avoid euphemisms for death! Go
around the family group to elicit everyone's perspective and promote
consensus. Educate patient/family about AND/DNR directives, CPR,
prognosis, palliative care and the dying process.
5. Physician states recommendations for EOL care (e.g., AND/DNR
directives, withdrawal of life-extending care, hospice referral)
a. Use physician's recommendation to ease burden of EOL decision-
making responsibility. Consider delaying decision making to facilitate
consultation with other family members or empirical trials of further
treatment to promote physicianfamily congruency.
b. Reassure the patient/family that they will not be abandoned before
death and that the medical team will do their best to minimize suffering
and promote comfort. Praise courage and support EOL decisions to
promote family cohesion.
6. Finalize the action plan
a. Summarize plan for EOL care, AND/DNR directives or withdrawal of
life-extending care.
b. Offer practical assistance and problem solve high priority issues: goals
of care, symptom management, spiritual needs and what to expect as
death approaches.
c. Set time for next meeting or update, elicit feedback.
After the patient's death, a bereavement call or a bereavement note is
a fine empathic gesture that will have a lasting and healing impact on
the family.
Physician: palliative care is our medical approach when the
cancer cannot be cured, infection is overwhelming and the heart
and kidneys are shutting down. This is unfortunately happening
with your father at the moment. The aim of our treatment now
focuses on reducing suffering and promoting comfort, so he can
pass away peacefully and naturally [empathic silence].
Sometimes we doctors use too many technical terms how
was my explanation? [checks understanding]
A second strategy is asking about past experiences with
death and dying. Most families have prior experiences with
death and these can inform the current case.
Physician: Have you ever faced a similar circumstance of a
family member or friend dying? What went well when
your grandfather died in home hospice? What could have
gone better?
A comforting, past experience with hospice may be
reassuring; negative experiences, such as a painful death, can
inform ways of improving EOL ICU care.
 T.T. Levin et al. / General Hospital Psychiatry 32 (2010) 433442
The third strategy is substituted judgment. Where a
patient lacks capacity, family can be invited to reflect on
who the patient is as a person and what their EOL wishes
might be if they could speak to us right now.
After discussing EOL care options, a clear physician
recommendation should guide the family, avoiding both
the extremes of paternalism and dumping the decision
on the family. Thus, the decision-making burden is truly
shared. This avoids the misperception that, e.g., we
killed grandma.
In making EOL recommendations, specific clinician
statements are associated with greater family satisfaction:
assurance that the patient will not be abandoned; assurance
that staff will do everything to maximize patient comfort and
minimize suffering and clinician support for the family's
decision to withdraw life-sustaining treatment [111].
Physician: This is a difficult situation. We will do our best to
help you through it. I think that we are making the most
reasonable decision, given the options [the we statement
reflects shared decision-making and support for the family]
Expressing admiration for the patient's and family's
strengths and praising their courage promote the family's
cohesiveness. Go around questioning is a technique that
can be used to reinforce consensus by inviting each family
member to contribute their thoughts.
Physician: John, what are your thoughts about letting your
dad die peacefully, as we have discussed? [Listens] Sally,
what about you?
Physicians should be alert to barriers blocking adaptive
decision making, e.g., where a patient expresses contradic-
tory wishes, such as both wanting to fight and desiring a
peaceful death [112]. Here a useful strategy is to encourage
planning for the best but also the worst possible outcome in
parallel, rather than viewing them as serial events.
3. Conclusions
The ICU has become an increasingly frequent site for the
implementation of EOL care and therefore critical care
physicians need to be competent in family-centered EOL
communication. They should be able to manage a family
meeting so as to promote consensus and discuss the
transition from curative to palliative goals of care, AND/
DNR directives, withdrawal of life-extending treatment and
the dying process.
The need for palliative care in the ICU setting is
predictable when viewed from a macro perspective. If a
large percentage of ICU patients receive balloon pumps,
clinicians are trained to use these devices. If 15-20% of ICU
patients die, clinicians need to be trained to deal with this
outcome. Here there is great opportunity for communication
training, reproducible algorithms and standards that reflect
439
multidisciplinary approaches to facilitate ICU palliative care
and support the family. Finally, emerging evidence suggests
that better EOL communication may impact on patient
outcomes such as the quality of the death, bereavement,
length of ICU admissions and cost of EOL care.
Acknowledgments
The authors gratefully acknowledge Drs. Malcolm Fisher,
Stephen Streat, Rinaldo Belloma, Stephen Warrillow and
Peter Saul for their thoughtful feedback on an earlier version
of this manuscript.
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