When Intensive Care Becomes Good End-of-Life Care.

Years ago, I began a research project with colleagues to demonstrate that physicians receive different, and arguably better, end-of-life care because of our greater knowledge about dying. We hypothesized, as had others, that physicians would be more likely to die at home, would be less likely to die in an ICU, and would generally receive less “aggressive” care. It took years to complete the study. The findings were not what we had expected: Physicians did receive more palliative care, but they also were more likely to die in an ICU and, among those with cancer, more likely to receive chemotherapy in the last 6 months of life; it was more of everything (1).

The work by Rolnick and colleagues (2) in this issue of the Journal (pp. 832–839), demonstrating that family satisfaction with end-of-life care for patients dying in the hospital is higher for patients who have received intensive care, is aligned with our findings, and it challenges the general belief regarding what constitutes a “good” death. The study forces us to reevaluate what we strive for as caregivers when we have conversations with patients and families, helping them to navigate the complex decision-making regarding where to go in the hospital for care. This finding regarding greater satisfaction was true among medical and surgical subgroups, as well as when focused on those with severe, life-limiting illnesses. Whether these responses were a reaction to intensive monitoring and invasive support or, as I suspect is often the case, to the reassurance of skilled caregivers is not answered by these data. Although overall satisfaction with care was high, a notable (and very concerning) finding was that only 50% of individuals believed that pain was well controlled.

As a physician who is responsible for determining which patients should or should not be admitted to an ICU, I have had my share of frustration admitting patients I believe I cannot help, that my efforts have been wasted because the patient will not leave the hospital or even the ICU. I have felt resentment toward patients and families who have insisted on coming to the ICU because I viewed intensive care primarily through the lens of what I and the rest of the team could do in terms of providing lifesaving therapies.

However, that has changed. The man I married just 6 years ago died in June 2019. He was diagnosed with metastatic cancer less than 2 years after our wedding and died 4 years after that. He received palliative care but also chemotherapy in his last week of life and died in the ICU; we were both intensive care physicians, and the story was exactly as told writ large in my own study.

There was clearly a comfort in the ICU—the knowledge that excellent nurses and doctors were always available. A symptom such as dyspnea is scary, either to experience oneself or to watch in someone you love. The reassurance of being sure that the symptom will be attended to and treated instantly (whether with escalating therapy or with opioids) cannot be overstated. I now see more than before what comfort can be provided through attentive care, even if it cannot result in a reversal of trajectory or a life saved.

With limited resources, ICUs cannot become the default for end-of-life care. But we need to look at what it is we provide in the ICU that may be lacking in some other places; at times, it may not be the machinery and monitoring but the reassurance and devotion of staff that are the real source of relief and satisfaction for patients and families who opt to say goodbye in that setting. As we move forward in seeking ways to improve the care of those who are dying, we can never underestimate the importance of compassion and support. Medicine remains as much about human contact and trust as about interventions, and we must strive to continue to identify the key aspects of our care that allow patients and families to say goodbye without regrets and with peace.

In gratitude to the many kind and generous caregivers in Toronto’s hospitals, and in memory of Dr. Brian Kavanagh.