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January 19, 2016

Toward Better ICU Use at the End of Life

Author Affiliations
  • 1Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 2Associate Editor, JAMA
  • 3Center for Bioethics, Harvard Medical School, Boston, Massachusetts
JAMA. 2016;315(3):255-256. doi:10.1001/jama.2015.18681

Are treatment in an intensive care unit (ICU) and good care at the end of life compatible processes or mutually exclusive? This Viewpoint examines arguments for and against intensive care at the end of life and proposes 5 strategies to help ensure the delivery of appropriate and optimal patient-centered care for patients at high risk of death or severe disability.

Some argue ICU admission at the end of life should be a “never” event. Three reasons support this argument. First, ICU care is characterized by the aggressive use of often invasive technology designed to rescue seriously ill patients from death. In contrast, high-quality end-of-life care provides patients with a “good death,” generally conceived as one without pain or unwanted interventions in the loving care of family and friends. Under this model, the former appears to impede the latter. Second, 1 in 5 US residents receive ICU care at the end of life,1 substantially contributing to the statistic that more than a quarter of Medicare dollars are spent on patients during the last year of life.2 Third, this rate of ICU use in the United States is higher than in many other countries, with no clear benefit in terms of life expectancy.3 Thus, ICU care in the United States at the end of life appears unwanted, expensive, and futile.

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