End-of-Life Care in the Cardiac Care Unit

End-of-Life Care in the Cardiac Care Unit

Janet M. Shapiro

Patients in the cardiac care unit (CCU) often undergo intensive and heroic treatments intended to save and prolong life. However, such patients managed in an intensive care unit (ICU) are at high risk of death. Many patients do undergo intensive care at the end of life; it has been projected that one in five Americans die in the ICU or subsequently during that hospitalization.1 The CCU has evolved over the past several decades such that the current CCU provides care to patients with advanced age and illness. Examination of recent temporal trends involving approximately 30,000 CCU patients revealed increases in noncardiovascular critical illness, including sepsis, acute renal injury, and acute respiratory failure as well as increasing use of procedures such as mechanical ventilation.2 Thus the CCU clinician is faced with critically patients who are on life support measures, some of whom may be at the end of life.

Decision making about end-of-life care in the CCU is a challenge for several reasons. Many patients do not have an advance directive. Even in cardiac patients with advanced interventions, including implantable electronic devices, discussions about advance directives are uncommon.3 Clinicians face difficulty in prognostication for critically ill patients. In patients with heart failure, variability in the course makes identifying the end of life especially challenging. The guidelines of the Heart Failure Society of America and the American College of Cardiology/American Heart Association promote consideration of end-of-life care in patients with advanced heart failure including decisions about inactivation of implantable defibrillators.4,5

It is notable that despite the recommendations of cardiology societies to encourage provision of supportive and palliative care, cardiology journals and textbooks have little end-of-life content compared with other specialties.6,7 Physicians in the CCU must be knowledgeable about end-of-life care; therefore, the goal of this chapter is to provide practical information about end-of-life decision-making and the process of withdrawal of life-sustaining treatments in the CCU.


As clinicians, our goals for patients are to save lives, restore health to a desirable existence, alleviate suffering, and provide the dying with a peaceful and dignified death.

The transition of the goal from curative treatment to comfort care is one of the most challenging aspects of critical care. People want to live; this is most exemplified by studies showing that patients would undergo mechanical ventilation for a 1% chance of ICU survival,8 and 70% of ICU survivors would undergo intensive care again for a chance to live one more month.9

Palliative care may even be provided in conjunction with lifesaving treatments in patients at risk for death. The goals of palliative care are control of symptoms such as pain, dyspnea, and discomfort; effective communication about appropriate goals of treatment and concordance of treatment with patient preferences; and enhancing quality of life. Adopting a palliative care approach and involving a palliative care service may be of great benefit in managing cardiac patients at the end of life.

Effective communication is the means to achieving patient preferences in end-of-life care. The landmark SUPPORT study revealed that the wishes of dying patients were often unexplored by physicians, and those patients received potentially undesired treatments at the end of life.10 Clinicians must also recognize that their own wishes may not coincide with those of their patients; a large multicenter study of European ICUs found that when asked about preferences at the end of life, physicians and nurses were less likely to desire life support than patients and families.11 Decision making that is shared between the patient/family and the clinicians is the model process supported by American and European critical care societies.12,13 The evolution of critical care decision-making from a paternalistic model to the current standard of shared decision-making is predicated on respect for patient autonomy and values. In the critical care unit, up to 95% of patients may be unable to participate in decisions owing to the severe illness, need for life support, and sedative medications.12 Therefore, the legally recognized appropriate surrogate often assumes the decision-making role to represent the patient’s values and preferences. The family-centered approach respects the patient’s values, and also acknowledges that many patients would want their family members to participate in decision making.


Patient autonomy is a foundation ethical principle for patient care. U.S. Supreme Court cases such as the Quinlan and Cruzan cases established that patients have a right to determine which medical treatments to accept or refuse, even when refusal leads to death.14 Often in the critical care unit, the patient is incapable of participating in the decision making. However, the patient may have left guidance in the form of an advance directive, such as a proxy, living will, or oral statements articulating
his or her wishes concerning life support at the end of life. The patient may have assigned a health care proxy to make decisions if he or she becomes unable to do so. If no proxy has been assigned, the surrogate decision maker is chosen from the patient’s close relatives or friends based on priority. In this way, the patient’s values and preferences can still guide the decision-making process when decision-making capacity is lost.

The principle of beneficence maintains that physicians will work to provide the best course of treatment for the patient. Physicians see the goal of preserving life, but beneficence also means the support of the patient’s informed decision even when refusal of therapy may lead to death. Nonmaleficence means not inflicting harm. This principle instructs the physician to weigh potential harms of treatments against potential benefits and not to provide interventions that will not benefit the patient.

Conflict may arise when the patient, family, and clinician disagree about the appropriateness of an intervention. Nonabandonment is an important principle that obliges the physician to help the family understand the situation and support the family’s decision. Physicians are not obligated to go against their own beliefs and therefore, if the physician disagrees with the patient and family decision, the principle of nonabandonment requires the physician to try to transfer care to another physician who will pursue the desired plan of care. The hospital administration or ethics committee may be involved to assist in resolution of these complicated situations.


As stated above, patient autonomy is the strongest ethical principle driving medical decision-making, so that patients have the right to make decisions for themselves, and when conscious capacity is lost, this right remains protected. Advance directives, such as the health care proxy and living will, provide for decision making based on patient values and preferences when the patient loses decision-making capacity. Respect for patient autonomy underlies the federal Patient Self-Determination Act of 1990 that requires hospital personnel to ask patients whether they have an advance directive and inform patients of their right to accept or refuse medical treatments and to create an advance directive.15 A do not resuscitate (DNR) order is one kind of advance directive that addresses interventions in the setting of a cardiopulmonary arrest. A DNR order means that if the patient suffers a cardiopulmonary arrest, the interventions of intubation, CPR, and advanced cardiovascular life support will be withheld. A DNR order is often issued for patients at the end of life and in patients with chronic or terminal illnesses. In some patients with DNR orders, the patient may be expected to benefit from and will receive intensive care interventions, but CPR will be withheld in the event of cardiac arrest. A DNR order is often a first step in the family’s decision-making process.


The means to decision making is effective communication and understanding. The contributions of the entire team are often invaluable. Most of ICU nurses do want to be involved in end-of-life decision-making; the bedside nurse usually has important insight into the patient’s condition and the family understands and desires. It should not be assumed that families grasp the severity of their relative’s illness or the ramifications of life support measures. Family understanding of critical illness and intensive care treatments has been shown to be inadequate.16 Among family members of ICU patients, only 50% could identify a single failing organ or any treatment.17 Knowledge about cardiopulmonary resuscitation is especially poor, with a prevalent unrealistic expectation of survival among patients with serious medical illness and their families.18 A prospective study in an urban American ICU found that only half of the surrogates understood basic facets of their family member’s care, such as whether the patient was on a respirator or the resuscitation status.16 Accordingly, assessing family members’ understanding of the patient condition is vital and will be part of the communication strategy in a family meeting.


Communication with the family occurs in several venues: bedside discussions, conversations with the nurse, telephone updates as well as a formal family meeting. A family meeting is an opportunity to present and review the situation and treatments, provide information on short-term and long-term prognosis, answer questions, explore patient and family values and wishes, and assess the family’s understanding of the patient’s condition.19 Investigators have examined family meetings and found missed opportunities in time allotted for family speech, articulating a prognosis, emphasizing the process of surrogate decision-making, supporting the decision, and assuring nonabandonment. Family satisfaction with the meeting was associated with increased time for family speech; presumably this is their opportunity to make the patient and his values known. Prognostication is important for family members, but more than one-third of examined deliberations lacked discussion of prognosis for survival. Investigators also found that less information about prognosis was provided to the less educated families.20 Although families may doubt the accuracy of the prognosis given by physicians, that prognostic information is desired and important in the family’s understanding and deliberation.21

Here, we can make some points about the family meeting:

  • The medical team should prepare for the family meeting. The clinicians should discuss the goals of the family meeting, review the patient’s condition, and achieve consensus concerning prognosis and treatments to be administered. The team should be aware of specific issues or problems related to the family situation. The bedside nurse may have great insight into the patient’s condition and family situation and should be included in the meeting.

  • The physician will lead the discussion in a private, quiet place. All participants should be introduced. The family should be asked their understanding of the condition and treatments. The physician should provide information about the illness, treatments including life support measures, and prognosis in a meaningful and compassionate manner by avoiding excessive medical jargon. The clinicians should explain surrogate and shared decision-making.

  • The clinicians should allow time for the family to speak about the patient’s values and preferences, to demonstrate their understanding of the situation, and to ask questions.

  • If withdrawal of life support is discussed, the clinicians should emphasize that this does not mean withdrawal of care and that supportive and comfort care will be provided.

  • The staff should offer support for the decision of the family, whether the decision is to withdraw or not withdraw life support. The team should assure the family that the patient will not be abandoned and all measures will be taken to prevent suffering.

  • The family cannot be rushed to make a decision. The meeting may conclude with a plan to reconvene in the following days to review the situation.

These discussions require time and experience. In many situations, the family members report that they never discussed end of life with the patient. Some ways to elucidate patient wishes include asking whether they ever had a conversation about the patient’s own wishes, in the setting of another family member’s illness or even related to a topic in the news; how the patient lived his life, what it may mean to be dependent in all aspects of care; what they think the patient might say about life support measures if he or she were in this meeting. The leader may ask the family what they believe is a meaningful and acceptable quality of life for the patient.

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May 27, 2016 | Posted by in CARDIAC SURGERY | Comments Off on End-of-Life Care in the Cardiac Care Unit
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