Dying patients in the intensive care unit: Forgoing treatment, maintainingcare

End-of-life care of patients in the intensive care unit (ICU) often require s dramatic shifts in attitudes and interventions, from traditional intensiv e rescue care to intensive palliative care. The care of patients dying in I CUs raises both clinical and ethical difficulties, Because fewer ICU patien ts are able to make decisions about withdrawing treatment, careful attentio n must be paid to previously expressed preferences and surrogate input Cult ural and spiritual values of patients and families may differ markedly from those of clinicians. Although prognostic models are increasingly able to p redict mortality rates for groups of ICU patients, their usefulness in guid ing specific decisions to forgo treatment has not been established. When a decision to forgo treatment is made, the focus should be on specifying the patient's goals of care and assessing all treatments in light of these goal s; interventions that do not contribute to the patient's goals should be di scontinued. Symptoms accompanying withdrawal of life support can almost alw ays be controlled with appropriate palliative measures. After ICU intervent ions are forgone, patient comfort must be the paramount objective. Whether in the ICU or elsewhere, hospitals have an ethical obligation to provide se ttings that offer dignified, compassionate, and skilled care.