Australian and New Zealand Intensive Care Society
Recommendations from the College of Intensive Care Medicine & the Australian and New Zealand Intensive Care Society on end-of-life care, invasive devices, anaemia, sedation & antibiotics. The Australian and New Zealand Intensive Care Society is the leading advocate on all intensive care related matters. ANZICS leads the world in intensive care research through its Clinical Trials Group and patient databases, including the Adult Patient Database, the Paediatric Intensive Care Registry and Critical Care Resources.
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For patients with limited life expectancy (such as advanced cardiac, renal or respiratory failure, metastatic malignancy, third line chemotherapy) ensure patients have a ‘goals of care’ discussion at or prior to admission to ICU and for patients in ICU who are at high risk for death or severely impaired functional recovery, ensure that alternative care focused predominantly on comfort and dignity is offered to patients and their families.
For patients with limited life expectancy (such as advanced cardiac, renal or respiratory failure, metastatic malignancy, third line chemotherapy) ensure patients have a ‘goals of care’ discussion at or prior to admission to ICU and for patients in ICU who are at high risk for death or severely impaired functional recovery, ensure that alternative care focused predominantly on comfort and dignity is offered to patients and their families.
The ANZICS Statement on Care and Decision Making at the End of Life for the Critically Ill states that the goal of intensive care is to return patients to a quality of life that is acceptable to them. In order to achieve this goal, it is essential that clinicians explore the values and preferences of each patient. Engaging with patients and their families in the discussions around treatment limitations or withdrawal can improve the quality of dying and reduce family and staff stress and bereavement.
Supporting evidence
- Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010;340:c1345.
- Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Critical Care Medicine 2008;36(3):953-63.
- Australian and New Zealand Intensive Care Society. ANZICS Statement on Care and Decision-Making at the End of Life for the Critically Ill (Edition 1.0). Melbourne, ANZICS, 2014.
- Fields MJ, Cassel CK. Approaching death, improving care at the end of life. Washington, D.C.: National Academy Press; 1997;437.
- Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, Rubenfeld GD, Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med 2004;32(3):638–43.
- Curtis JR, Engelberg RA, Wenrich MD, Shannon SE, Treece PD, Rubenfeld GD. Missed opportunities during family conferences about end-of-life care in the intensive care unit. Amer J Respir Crit Care Med 2005;171:844–9.
- Gries CJ, Engelberg RA, Kross EK, Zatzick D, Nielsen EL, Downey L, Curtis JR. Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU. Chest 2010;137(2):280–7.
- Prigerson HG, Bao Y, Shah MA, et al. Chemotherapy use, performance status, and quality of life at the end of life. JAMA Oncol 2015;1(6):778-84.
How this list was made
A working group of interested parties from both CICM and ANZICS was formed to develop a list of 12 items that they believe should be focused on to reduce the number of unnecessary tests and interventions performed in intensive care. All CICM Fellows and ANZICS members were surveyed to develop a consensus view of a final list of five items. There were 6 items clearly favoured and two of these were combined by the working group to develop the final 5 recommendations.
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For patients with limited life expectancy (such as advanced cardiac, renal or respiratory failure, metastatic malignancy, third line chemotherapy) ensure patients have a ‘goals of care’ discussion at or prior to admission to ICU and for patients in ICU who are at high risk for death or severely impaired functional recovery, ensure that alternative care focused predominantly on comfort and dignity is offered to patients and their families.
- 2 Remove all invasive devices, such as intravascular lines and urinary catheters, as soon as possible.
- 3 Transfuse red cells for anaemia only if the haemoglobin concentration is less than 70gm/L or if the patient is haemodynamically unstable or has significant cardiovascular or respiratory comorbidity.
- 4 Undertake daily attempts to lighten sedation in ventilated patients unless specifically contraindicated and deeply sedate mechanically ventilated patients only if there is a specific indication.
- 5 Consider antibiotic de-escalation daily.