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Managing Death in the ICU: The Transition From Cure to Comfort FREE TO VIEW

Beth Chaitin, DHCE; Robert Arnold, MD
Author and Funding Information

Affiliations: 1Director, Comprehensive Palliative Care, University of Pittsburgh, Pittsburgh, PA,  2Director, Medical Ethics and Palliative Care Services

Affiliations: 1Director, Comprehensive Palliative Care, University of Pittsburgh, Pittsburgh, PA,  2Director, Medical Ethics and Palliative Care Services

Chest. 2001;120(4):1428-1429. doi:10.1378/chest.120.4.1428-a
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By J. Randall Curtis and Gordon D. Rubenfeld, eds. New York, NY: Oxford University Press Inc., 2001; 408 pp; $59.95

Some health professionals believe that palliative ICU care is an oxymoron, for example, the authors of the SUPPORT study who treated death in the ICU as a “bad” outcome. Unfortunately, in many tertiary-care institutions, more patients die in the ICU than anywhere else in the hospital, making the management of death a more common task for ICU staff than restoring health. On the other hand, we should also be careful not to impose our values on patients who are often willing to endure intensive care despite a low probability of survival.

Managing Death in the ICU: The Transition From Cure to Comfort successfully deals with the complexity of juggling perspectives on cure and comfort in the ICU. Drs. Curtis and Rubenfeld achieve this feat by defining the extent of the problem in initial sections entitled “The Decision to Limit Life Support in the ICU” and “Practical Skills Needed to Manage Death in the ICU,” and then further expanding on these themes in later sections. The editors have enlisted the support of well-respected authors from various fields who provide important information from their individual specialties. The final result is a well-organized text with a clear flow of material from broad overview to focused detail.

The text contains a good balance of clinical information that addresses commonly confronted problems facing the practitioner, as well as providing unique information in specialty areas such as oncology, cardiology, the care of dying children, and the elderly. The clinical information is clearly written and can serve as a quick reference guide for both the clinician and the nonclinician alike. The chapters covering pain and symptom control in the dying ICU patient and on withdrawing life-sustaining treatment are particularly helpful.

Drs. Curtis and Rubenfeld are also careful to provide a mixture of nonmedical information with respect to ethical, emotional, social, and spiritual concerns that are frequently faced when caring for the dying patient in the ICU. These chapters vary in focus and at times contain only brief information on issues that could benefit from more detail. For example, a discussion of ethical implications is perceptibly missing from the chapter on the withdrawal of life-sustaining therapy.

A particular strength of the book is the inclusion of topics that are often ignored by clinicians. For example, Nancy Chambers and J. Randall Curtis discuss the role of spirituality in the technological atmosphere of modern medicine. Included is an interesting table that summarizes how individuals of differing faiths might respond to critical illness, which could serve as a good pocket resource. Another high point of the book is a piece written by Susan D. Block entitled “Helping the Clinician Cope with Death in the ICU,” which skillfully discusses both the similarities and differences between palliative care and intensive care. Dr. Block brings to light common conflicting issues faced in the ICU, including role conflict, staff conflict, anger, distancing, and the intellectualization of death. Her words reflect back to the reader the negative feelings that accompany the helplessness and frustration that many feel when caring for dying patients in the ICU.

The book is relatively comprehensive and covers most of the issues that we have faced in caring for the dying ICU patient. However, we do wish that that there had been more explicit attention paid to the problem of uncertainty in caring for the critically ill. The problem for most patients (and their health-care providers) is knowing when they have gone from critically ill to “dying.” Neither physicians nor families want to “give up” too early. Thus, a chapter dealing with the psychosocial, communication, and ethical issues that this raises would have been a valuable addition.

Nonetheless, this book presents compelling evidence that, rather than being an oxymoron, palliative ICU care is an idea whose time has come. Managing Death in the ICU: The Transition from Cure to Comfort is a valuable educational resource for all who care for patients in the ICU.




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