An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units

Beyond the healthcare system: The societal and contextual factors impacting parents' participation in decision-making for neonates with life-threatening conditions

BACKGROUND

Parents of neonates with life-threatening conditions and professionals, bear the burden of making complex decisions. Parents may not be fully involved in decision-making, and there is a paucity of evidence regarding the influence of social context on parents' participation. We aimed to explore factors that extended beyond the healthcare system and impacted parents' participation in decision-making for neonates with life-threatening conditions.

MATERIALS AND METHODS

This qualitative research was carried out in 2019 in four level-III Iranian NICUs, (neonatal intensive care units) where twenty-three face-to-face semi-structured interviews were conducted, transcribed, and analyzed using a conventional content analysis technique. Interviews were condensed into meaningful units during the coding phase, resulting in 206 open codes. These codes were then categorized into eleven categories based on commonalities and distinctions. This iterative process continued until 4 main subcategories were established.

RESULTS

The main categories and sub-categories were "unmodified regulations according to the neonatology advances" (lack of regulations to modify ineffective treatments, lack of a legally documented do not resuscitate order, lack of a defined regional neonatal viability threshold, and lack of maternal guardianship of child medical care), "deficiencies of the health insurance system" (covering the cost of ineffective treatments and lack of insurance covering for palliative care services), "treatment-oriented culture in society" (expecting a miracle for medical science, difficult acceptance of neonatal death and difficult acceptance of home death), and "physician-oriented culture in society" (excessive respect for physicians' decision-making eligibility and social position of physicians).

CONCLUSION

The findings revealed concepts surrounding parents' participation in decision-making for life-threatening conditions neonates are influenced by social, legal, cultural, and financial aspects. To bridge the gap between healthcare professionals' attitudes and cultural and religious beliefs, fatwas, and laws, a collaborative approach is necessary. To address the complex challenges of decision-making for these neonates, involving stakeholders like clinicians, legal experts, Islamic scholars, sociologists, jurists, judges, and medical ethicists is crucial for modifying laws to align with neonatology advancements.

End-of-life Care in the Intensive Care Unit and Ethics of Withholding/Withdrawal of Life-sustaining Treatments

The medical progress has produced improvements in critically ill patients' survival to early phases of life-threatening diseases, thus producing long intensive care stays and persisting disability, with uncertain long-term survival rates and quality of life. Thus, compassionate end-of-life care and the provision of palliative care, even overlapping with the most aggressive of curative intensive care unit (ICU) care has become crucial. Moreover, withdrawal or withholding of life-sustaining treatment may be adopted, allowing unavoidable deaths to occur, without prolonging agony or ICU stay. Our aim was to summarize the key element of end-of-life care in the ICU and the ethics of withholding/withdrawal life-sustaining treatments.

Physicians' experiences and perceptions about withholding and withdrawal life-sustaining treatment in Chiang Mai University Hospital: a cross-sectional study

BACKGROUND

Withholding or withdrawing life-sustaining treatment in end-of-life patients is a challenging ethical issue faced by physicians. Understanding physicians' experiences and factors influencing their decisions can lead to improvement in end-of-life care.

OBJECTIVES

To investigate the experiences of Thai physicians when making decisions regarding the withholding or withdrawal of life-sustaining treatments in end-of-life situations. Additionally, the study aims to assess the consensus among physicians regarding the factors that influence these decisions and to explore the influence of families or surrogates on the decision-making process of physicians, utilizing case-based surveys.

METHODS

A web-based survey was conducted among physicians practicing in Chiang Mai University Hospital (June - October 2022).

RESULTS

Among 251 physicians (response rate 38.3%), most of the respondents (60.6%) reported that they experienced withholding or withdrawal treatment in end-of-life patients. Factors that influence their decision-making include patient's preferences (100%), prognosis (93.4%), patients' quality of life (92.8%), treatment burden (89.5%), and families' request (87.5%). For a chronic disease with comatose condition, the majority of the physicians (47%) chose to continue treatments, including cardiopulmonary resuscitation (CPR). In contrast, only 2 physicians (0.8%) would do everything, in cases when families or surrogates insisted on stopping the treatment. This increased to 78.1% if the families insisted on continuing treatment.

CONCLUSION

Withholding and withdrawal of life-sustaining treatments are common in Thailand. The key factors influencing their decision-making process included patient's preferences and medical conditions and families' requests. Effective communication and early engagement in advanced care planning between physicians, patients, and families empower them to align treatment choices with personal values.

[Palliative neurology]

Palliative medicine represents the holistic multiprofessional treatment of severely and incurably ill people and their relatives, addressing their complex physical, psychological, social and spiritual needs. The central therapeutic goals are the quality of life and alleviation of suffering. In the course of many neurological diseases, high symptom burden, long and variable trajectories and unfavorable prognosis at times create a need for palliative care even at an early stage, which is currently still inadequately met. This can be countered by qualified neuropalliative care. In addition to intensifying interdisciplinary collaboration, this requires neurologists to have core competencies in palliative care. These include a team-oriented attitude, communication skills, expertise in symptom control and knowledge of biomedical ethics including palliative options at the end of life.

Defining Death: Toward a Biological and Ethical Synthesis

Much of the debate over the definition and criteria for determining our death has focused on disagreement over the correct biological account of death, i.e., what it means for any organism to die. In this paper, we argue that this exclusive focus on the biology of death is misguided, because it ignores ethical and social factors that bear on the acceptability of criteria for determining our death. We propose that attention shift from strictly biological considerations to ethical and social considerations that bear on the determination of what we call "civil death." We argue for acceptance of a neurological criterion for determining death on grounds that it is the most reasonable way to synthesize biological, ethical, and social considerations about our death..

Traumatic Brain Injury as an Independent Predictor of Futility in the Early Resuscitation of Patients in Hemorrhagic Shock

This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.

In-Hospital Triage

The intensive care unit (ICU) is a finite and expensive resource with demand not infrequently exceeding capacity. Understanding ICU capacity strain is essential to gain situational awareness. Increased capacity strain can influence ICU triage decisions, which rely heavily on clinical judgment. Having an admission and triage protocol with which clinicians are very familiar can mitigate difficult, inappropriate admissions. This article reviews these concepts and methods of in-hospital triage.

On What Grounds? A Pilot Study of References Used in Clinical Ethics Consultation and Education

In accordance with standards published by the American Society for Bioethics and Humanities (ASBH), ethics consultants are expected to provide recommendations that align with scholarly literature, professional society statements, law, and policy. However, there are no studies to date that characterize the specific references that ethics consultants and educators use to inform their work. To address this gap, a convenience sample of clinical ethics consultants and educators was surveyed online through two major listservs for clinical ethics, the ASBH Clinical Ethics Consultation Affinity Group (CECAG) and the Association of Bioethics Program Directors (ABPD). Ninety-five ethics consultants and/or educators with diverse educational background, credentials, and experience provided responses. In total, 451 references, 315 of which were unique, were reported. These references were broken into 6 categories after analysis: bioethics literature (divided into articles and books), professional society documents (divided into professional society statements and codes of ethics), federal/state/uniform/case law, hospital/health system policies, official religious teachings, and other. We found extensive variation and minimal overlap in the references respondents used for ethics consultation and education, even when referring to the same topics. Future research directions should include conducting more systematic efforts to characterize the references used by ethics consultants across the US; determining whether demographic characteristics of consultants influence the references used; and ascertaining whether the variation in references used reflects genuine disagreements in consultants' and educators' bioethical analysis or recommendations.

Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study

Background and aim

While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored.

Methods

There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes.

Results

About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC.

Conclusion

Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians.

How to cite this article

Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.

Hospital Policy Variation in Addressing Decisions to Withhold and Withdraw Life-Sustaining Treatment

BACKGROUND

Sociodemographic disparities in physician decisions to withhold and withdraw life-sustaining treatment exist. Little is known about the content of hospital policies that guide physicians involved in these decisions.

RESEARCH QUESTION

What is the prevalence of US hospitals with policies that address withholding and withdrawing life-sustaining treatment; how do these policies approach ethically controversial scenarios; and how do these policies address sociodemographic disparities in decisions to withhold and withdraw life-sustaining treatment?

STUDY DESIGN AND METHODS

This national cross-sectional survey assessed the content of hospital policies addressing decisions to withhold or withdraw life-sustaining treatment. We distributed the survey electronically to American Society for Bioethics and Humanities members between July and August 2023 and descriptively analyzed responses.

RESULTS

Among 93 respondents from hospitals or hospital systems representing all 50 US states, Puerto Rico, and Washington, DC, 92% had policies addressing decisions to withhold or withdraw life-sustaining treatment. Hospitals varied in their stated guidance, permitting life-sustaining treatment to be withheld or withdrawn in cases of patient or surrogate request (82%), physiologic futility (81%), and potentially inappropriate treatment (64%). Of the 8% of hospitals with policies that addressed patient sociodemographic disparities in decisions to withhold or withdraw life-sustaining treatment, these policies provided opposing recommendations to either exclude sociodemographic factors in decision-making or actively acknowledge and incorporate these factors in decision-making. Only 3% of hospitals had policies that recommended collecting and maintaining information about patients for whom life-sustaining treatment was withheld or withdrawn that could be used to identify disparities in decision-making.

INTERPRETATION

Although most surveyed US hospital policies addressed withholding or withdrawing life-sustaining treatment, these policies varied widely in criteria and processes. Surveyed policies also rarely addressed sociodemographic disparities in these decisions.

Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit

End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs.

How to cite this article

Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.

Futile life-sustaining treatment in the intensive care unit - nurse and physician experiences: meta-synthesis

BACKGROUND

Continuing futile life-sustaining treatment prolongs patients' suffering and family members' and medical staff's psychological distress. Additionally, continuing futile treatment is inefficient in healthcare resource distribution. Although the withdrawal of futile life-sustaining treatment is ideal, the prevalence is variable.

OBJECTIVE

To synthesise nurses' and physicians' experiences with continuing futile life-sustaining treatment in the intensive care unit.

DESIGN

This meta-synthesis was conducted following the thematic synthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses and Enhancing transparency in reporting the synthesis of qualitative research statement were used in reporting the synthesis of qualitative research statements.

METHODS AND DATA SOURCES

A systematic search was conducted following the inclusion and exclusion criteria in APA PsycINFO, CINAHL Plus, EMBASE, MEDLINE, PubMed and Web of Science in May 2023. Two reviewers independently screened and extracted the data. The extracted data were analysed using thematic analysis of qualitative research.

FINDINGS

A total of 16 studies were finally included, and 141 quotes were extracted and analysed. The main findings were categorised into four themes: (1) contextual and cultural diversity, (2) perceptions of futile treatment, (3) professional roles and responsibilities, and (4) emotional distress.

CONCLUSION

The study highlights the influence of culture, religion and family members, as well as perceptions of futile treatment among clinicians, on continuing futile life-sustaining treatment. Also, nurses' awareness of their roles and responsibilities in ensuring patients' comfort at end of life was revealed. This study informs future research to explore the experiences of futile life-sustaining treatment across various contexts.

Shared Decision-Making in Pediatrics

This article briefly reviews a 4-step process for implementing shared decision-making (SDM) in pediatrics. The authors address difficulties with determining whether SDM should occur and comment on how the SDM process relates to, and may be conflated with, other decision-making models that leverage similar patient-centered and family-centered communication strategies.

The trajectory of very old critically ill patients

The demographic shift, together with financial constraint, justify a re-evaluation of the trajectory of care of very old critically ill patients (VIP), defined as older than 80 years. We must avoid over- as well as under-utilisation of critical care interventions in this patient group and ensure the inclusion of health care professionals, the patient and their caregivers in the decision process. This new integrative approach mobilises expertise at each step of the process beginning prior to intensive care unit (ICU) admission and extending to long-term follow-up. In this review, several international experts have contributed to provide recommendations that can be universally applied. Our aim is to define a minimum core dataset of information to be shared and discussed prior to ICU admission and to facilitate the shared-decision-making process with the patient and their caregivers, throughout the patient journey. Documentation of uncertainty may contribute to a tailored level of care and ultimately to discussions around possible limitations of life sustaining treatments. The goal of ICU care is not only to avoid death, but more importantly to maintain an acceptable quality of life and functional autonomy after hospital discharge. Societal consideration is important to highlight, together with alternatives to ICU admission. We discuss challenges for the future and potential areas of research. In summary, this review provides a state-of-the-art current overview and aims to outline future directions to address the challenges in the treatment of VIP.

A Case Series of Patients With Complex Airway Disease and Large Thyroid Tumors Anterior to the Trachea Precluding Tracheostomy

BACKGROUND

This case series explores the management of respiratory failure in patients with large anterior tracheal thyroid tumors where tracheostomy is not an option. To our knowledge, this study is the first to address the challenges associated with caring for such patients.

CASE SUMMARY

We present the clinical courses of four intubated adults with advanced thyroid cancer and complex airway issues that preclude surgical tracheostomy. Interventions included custom airway stents, long-term intubation, and oncological therapies. Ethical quandaries around patient autonomy and capacity emerged, exacerbated by the absence of viable exit strategies for prolonged intubation, notably the performance of a tracheostomy, causing emotional distress in patients, families, and staff.

CONCLUSIONS

This study showcases the multifaceted challenges in medical, ethical, and emotional domains associated with managing intubated patients with complex disease precluding tracheotomies. We advocate for a nuanced, multidisciplinary, and personalized approach to confront unique issues in airway management, ethical considerations, and disposition.

Catholic Teaching: A Middle Ground and Guide for End-of-Life Care and Decision-Making and an Antidote for Dying Badly in America

Dying in the United States is characterized as: medicalized, depersonalized, high technology, fragmented with frequent transitions among care settings, burdensome to patients and families, driven by efficiency and effectiveness, and lacking in key areas, for example, access to palliative care and adequate pain and symptom treatment. Patients and families are often left with a choice of two extremes: vitalism or utilitarian pessimism (utilitarianism). The Catholic Church, however, rejects both of these extremes, and Catholic social teaching (CST) at end of life focuses on ordinary-extraordinary treatments/means, a culture of life and human dignity, accompaniment and community, and caring for whole persons through the end of life. The Catholic tradition of ordinary-extraordinary means is helpful to guide complex end-of-life decisions, regardless of one's religious beliefs, and offers a middle ground between vitalism and utilitarianism that can inform end-of-life care and decision-making for all patients in Catholic health care. While it does not provide answers, it offers guidance and enables conversations that are crucial for the dying and their families to make autonomous, informed decisions about end-of-life care. It provides an opportunity for the dying to let the care team, loved ones, and decision-makers know what a life with meaning, purpose, and passion is for them-and how they want to live and die. This article will summarize the problem, describe end-of-life Catholic teaching, and discuss how it offers a middle-ground. Arguments for and against vitalism and utilitarianism will be explored, including a discussion of CST's response to those receiving care in Catholic health care facilities who are outside the Catholic tradition and do not believe in the teaching. The last section describes a model of collaborative partnership where local parishes and Catholic health care come together to tackle the challenges of caring for and ministering to the seriously ill and those facing death.

Perceived potentially inappropriate treatment in the PICU: frequency, contributing factors and the distress it triggers

Background

Potentially inappropriate treatment in critically ill adults is associated with healthcare provider distress and burnout. Knowledge regarding perceived potentially inappropriate treatment amongst pediatric healthcare providers is limited.

Objectives

Determine the frequency and factors associated with potentially inappropriate treatment in critically ill children as perceived by providers, and describe the factors that providers report contribute to the distress they experience when providing treatment perceived as potentially inappropriate.

Methods

Prospective observational mixed-methods study in a single tertiary level PICU conducted between March 2 and September 14, 2018. Patients 0-17 years inclusive with: (1) ≥1 organ system dysfunction (2) moderate to severe mental and physical disabilities, or (3) baseline dependence on medical technology were enrolled if they remained admitted to the PICU for ≥48 h, and were not medically fit for transfer/discharge. The frequency of perceived potentially inappropriate treatment was stratified into three groups based on degree of consensus (1, 2 or 3 providers) regarding the appropriateness of ongoing active treatment per enrolled patient. Distress was self-reported using a 100-point scale.

Results

Of 374 patients admitted during the study, 133 satisfied the inclusion-exclusion criteria. Eighteen patients (unanimous - 3 patients, 2 providers - 7 patients; single provider - 8 patients) were perceived as receiving potentially inappropriate treatment; unanimous consensus was associated with 100% mortality on 3-month follow up post PICU discharge. Fifty-three percent of providers experienced distress secondary to providing treatment perceived as potentially inappropriate. Qualitative thematic analysis revealed five themes regarding factors associated with provider distress: (1) suffering including a sense of causing harm, (2) conflict, (3) quality of life, (4) resource utilization, and (5) uncertainty.

Conclusions

While treatment perceived as potentially inappropriate was infrequent, provider distress was commonly observed. By identifying specific factor(s) contributing to perceived potentially inappropriate treatment and any associated provider distress, organizations can design, implement and assess targeted interventions.

"Death as the One Great Certainty": ethical implications of children with irreversible cardiorespiratory failure and dependence on extracorporeal membrane oxygenation

Introduction

Advances in medical technology have led to both clinical and philosophical challenges in defining death. Highly publicized cases have occurred when families or communities challenge a determination of death by the irreversible cessation of neurologic function (brain death). Parallels can be drawn in cases where an irreversible cessation of cardiopulmonary function exists, in which cases patients are supported by extracorporeal cardiopulmonary support, such as extracorporeal membrane oxygenation (ECMO).

Analysis

Two cases and an ethical analysis are presented which compare and contrast contested neurologic determinations of death and refusal to accept the irreversibility of an imminent death by cardiopulmonary standards. Ambiguities in the Uniform Determination of Death Act are highlighted, as it can be clear, when supported by ECMO, that a patient could have suffered the irreversible cessation of cardiopulmonary function yet still be alive (e.g., responsive and interactive). Parallel challenges with communication with families around the limits of medical technology are discussed.

Discussion

Cases that lead to conflict around the removal of technology considered not clinically beneficial are likely to increase. Reframing our goals when death is inevitable is important for both families and the medical team. Building relationships and trust between all parties will help families and teams navigate these situations. All parties may require support for moral distress. Suggested approaches are discussed.

Conscientious Objection to Aggressive Interventions for Patients in a Vegetative State

Some physicians refuse to perform life-sustaining interventions, such as tracheostomy, on patients who are very likely to remain permanently unconscious. To explain their refusal, these clinicians often invoke the language of "futility", but this can be inaccurate and can mask problematic forms of clinical power. This paper explores whether such refusals should instead be framed as conscientious objections. We contend that the refusal to provide interventions for patients very likely to remain permanently unconscious meets widely recognized ethical standards for the exercise of conscience. We conclude that conscientious objection to tracheostomy and other life-sustaining interventions on such patients can be ethical because it does not necessarily constitute a form of invidious discrimination. Furthermore, when a physician frames their refusal as conscientious objection, it makes transparent the value-laden nature of their objection and can better facilitate patient access to the requested treatment.

Navigating parental requests: considering the relational potential standard in paediatric end-of-life care in the paediatric intensive care unit

Families and clinicians approaching a child's death in the paediatric intensive care unit (PICU) frequently encounter questions surrounding medical decision-making at the end of life (EOL), including defining what is in the child's best interest, finding an optimal balance of benefit over harm, and sometimes addressing potential futility and moral distress. The best interest standard (BIS) is often marshalled by clinicians to help navigate these dilemmas and focuses on a clinician's primary ethical duty to the paediatric patient. This approach does not consider a clinician's potential duty to the patient's family. This paper argues that when a child is dying in the PICU, the physician has a duty to serve both the patient and the family, and that in some circumstances, the duty to serve the family becomes as important as that owed to the child. We detail the limitations of the BIS in paediatric EOL care and propose the relational potential standard as an additional ethical framework to guide our decisions.

Agent-Regret in Healthcare

For healthcare professionals and organizations, there is an emphasis on addressing moral distress and compassion fatigue among clinicians. While addressing these issues is vital, this paper suggests that the philosophical concept of agent-regret is a relevant but overlooked issue in healthcare. To experience agent-regret is to regret your harmful but not wrongful actions. This person's action results in someone being killed or significantly injured, but it was ethically faultless. Despite being faultless, agent-regret is an emotional response concerning one's agency in a situation that results in death or significant harm. In healthcare, many clinicians are likely to experience regret for faultless actions that significantly harm or cause the death of a patient. The recognition of agent-regret in healthcare is significant because it differs, conceptually and practically, from moral distress and compassion fatigue. Building on the work of Wojtowicz (2022), we should strive to understand clinicians' agent-regret by recognizing their agency in the situation, not lessening or removing it.

Becoming futile: the emotional pain of treating COVID-19 patients

Introduction

The COVID-19 pandemic has had a profoundly detrimental impact on the emotional wellbeing of health care workers. Numerous studies have shown that their rates of the various forms of work-related distress, which were already high before the pandemic, have worsened as the demands on health care workers intensified. Yet much less is known about the specific social processes that have generated these outcomes. This study adds to our collective knowledge by focusing on how one specific social process, the act of treating critically ill COVID-19 patients, contributed to emotional pain among health care workers.

Methods

This article draws from 40 interviews conducted with intensive care unit (ICU) staff in units that were overwhelmed with COVID-19 patients. The study participants were recruited from two suburban community hospitals in Massachusetts and the interviews were conducted between January and May 2021.

Results

The results show that the uncertainty over how to treat critically ill COVID-19 patients, given the absence of standard protocols combined with ineffective treatments that led to an unprecedented number of deaths caused significant emotional pain, characterized by a visceral, embodied experience that signaled moral distress, emotional exhaustion, depersonalization, and burnout. Furthermore, ICU workers' occupational identities were undermined as they confronted the limits of their own abilities and the limits of medicine more generally.

Discussion

The inability to save incurable COVID-19 patients while giving maximal care to such individuals caused health care workers in the ICU an immense amount of emotional pain, contributing to our understanding of the social processes that generated the well-documented increase in moral distress and related measures of work-related psychological distress. While recent studies of emotional socialization among health care workers have portrayed clinical empathy as a performed interactional strategy, the results here show empathy to be more than dramaturgical and, in this context, entailed considerable risk to workers' emotional wellbeing.

Patients' Perspective on Termination of Pacemaker Therapy-A Cross-Sectional Anonymous Survey among Patients Carrying a Pacemaker in Germany

OBJECTIVE

To determine the opinions of patients regarding the withdrawal of pacemaker therapy.

PARTICIPANTS AND METHODS

A cross-sectional anonymous questionnaire was administered to patients visiting an outpatient cardiologic clinic for routine follow-up visits of pacemaker therapy or patients carrying a pacemaker admitted to a hospital between 2021 and 2022.

RESULTS

Three-hundred and forty patients answered the questionnaire. A total of 56% of the participants were male. The mean age was 81 years. The majority of respondents were very comfortable with their PM and felt well informed, with one exception: more than half of respondents were missing information on withdrawal of pacemaker therapy. Almost two-thirds wanted to decide for themselves if their pacemaker therapy was withdrawn regardless of whether they were ill or healthy. Almost 60% of patients would like the pacemaker to be turned off when dying. Women expressed this wish significantly more often than men.

CONCLUSION

Our survey shows that patients prefer to be informed on issues regarding the withdrawal of pacemakers as early as preimplantation. Also, patients would like to be involved in decisions that have to be made at the end of life, including decisions on withdrawal. Offers of conversations about this important issue should include information on special features of the patient's pacemaker, e.g., the absence or presence of pacemaker dependency. Knowledge about the pacemaker's functionality may prevent distress among individuals nearing their end of life when, for example, under the false impression that timely deactivation may allow for a more peaceful death.

Clinician Moral Distress: Toward an Ethics of Agent-Regret

Moral distress names a widely discussed and concerning clinician experience. Yet the precise nature of the distress and the appropriate practical response to it remain unclear. Clinicians speak of their moral distress in terms of guilt, regret, anger, or other distressing emotions, and they often invoke them interchangeably. But these emotions are distinct, and they are not all equally fitting in the same circumstances. This indicates a problematic ambiguity in the moral distress concept that obscures its distinctiveness, its relevant circumstances, and how individual clinicians and the medical community should practically respond to it. We argue that, in a range of situations that are said to be morally distressing, the characteristic emotion can be well-understood in terms of what Bernard Williams calls "agent-regret." We show what can thereby be gained in terms of a less ambiguous concept and a more adequate ethical response to this distinctive and complex clinician experience.

Limiting life-sustaining treatment for very old ICU patients: cultural challenges and diverse practices

BACKGROUND

Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies.

METHODS

Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems.

RESULTS

This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries.

CONCLUSIONS

This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field.

Declining to Provide or Continue Requested Life-Sustaining Treatment: Experience With a Hospital Resolving Conflict Policy

In 2015, the major critical care societies issued guidelines outlining a procedural approach to resolving intractable conflict between healthcare professionals and surrogates over life-sustaining treatments (LST). We report our experience with a resolving conflict procedure. This was a retrospective, single-centre cohort study of ethics consultations involving intractable conflict over LST. The resolving conflict process was initiated eleven times for ten patients over 2,015 ethics consultations from 2000 to 2020. In all cases, the ethics committee recommended withdrawal of the contested LST. In seven cases, the patient died or was transferred or a legal injunction was obtained before completion of the process. In the four cases in which LST was withdrawn, the time from ethics consultation to withdrawal of LST was 24.8 ± 12.2 days. Healthcare provider and surrogate were often distressed during the process, sometimes resulting in escalation of conflict and legal action. In some cases, however, surrogates appeared relieved that they did not have to make the final decision regarding LST. Challenges regarding implementation included the time needed for process completion and limited usefulness in emergent situations. Although it is feasible to implement a due process approach to conflict over LST, there are factors that limit the procedure's usefulness.

Outcomes in Patients Perceived as Receiving Excessive Care by ICU Physicians and Nurses: Differences Between Patients < 75 and ≥ 75 Years of Age?

BACKGROUND

The benefit of the ICU for older patients is often debated. There is little knowledge on subjective impressions of excessive care in ICU nurses and physicians combined with objective patient data in real-life cases.

RESEARCH QUESTION

Is there a difference in treatment limitation decisions and 1-year outcomes in patients < 75 and ≥ 75 years of age, with and without concordant perceptions of excessive care by two or more ICU nurses and physicians?

STUDY DESIGN AND METHODS

This was a reanalysis of the prospective observational DISPROPRICUS study, performed in 56 ICUs. Nurses and physicians completed a daily questionnaire about the appropriateness of care for each of their patients during a 28-day period in 2014. We compared the cumulative incidence of patients with concordant perceptions of excessive care, treatment limitation decisions, and the proportion of patients attaining the combined end point (death, poor quality of life, or not being at home) at 1 year across age groups via Cox regression with propensity score weighting and Fisher exact tests.

RESULTS

Of 1,641 patients, 405 (25%) were ≥ 75 years of age. The cumulative incidence of concordant perceptions of excessive care was higher in older patients (13.6% vs 8.5%; P < .001). In patients with concordant perceptions of excessive care, we found no difference between age groups in risk of death (1-year mortality, 83% in both groups; P > .99; hazard ratio [HR] after weighting, 1.11; 95% CI, 0.74-1.65), treatment limitation decisions (33% vs 31%; HR after weighting, 1.11; 95% CI, 0.69-2.17), and reaching the combined end point at 1 year (90% vs 93%; P = .546). In patients without concordant perceptions of excessive care, we found a difference in risk of death (1-year mortality, 41% vs 30%; P < .001; HR after weighting, 1.38; 95% CI, 1.11-1.73) and treatment limitation decisions (11% vs 5%; P < .001; HR, 2.11; 95% CI, 1.37-3.27); however, treatment limitation decisions were mostly documented prior to ICU admission. The risk of reaching the combined end point was higher in the older adults (61.6% vs 52.8%; P < .001).

INTERPRETATION

Although the incidence of perceptions of excessive care is slightly higher in older patients, there is no difference in treatment limitation decisions and 1-year outcomes between older and younger patients once patients are identified by concordant perceptions of excessive care. Additionally, in patients without concordant perceptions, the outcomes are worse in the older adults, pleading against ageism in ICU nurses and physicians.

ICU stays that are judged to be non-beneficial: A qualitative study of the perception of nursing staff

INTRODUCTION

Non-beneficial stays in the intensive care unit (ICU) may have repercussions for patients and their families, but can also cause suffering among the nursing staff. We aimed explore the perceptions of nursing staff in the ICU about patient stays that are deemed to be "non-beneficial" for the patient, to identify areas amenable to intervention, with a view to improving how the nursing staff perceive the patient pathway before, during and after intensive care.

METHODS

Multicentre, qualitative study using individual, semi-structured interviews. All qualified nurses and nurses' aides who were full-time employees in the ICU of three participating centres were invited to participate. Interviews were recorded, transcribed and analyzed using textual content analysis.

RESULTS

A total of 21 interviews were performed from February 2020 to October 2021, at which point saturation was reached in the data. Average age of participants was 38.5±7.5 years, and they had an average of 10.7±7.4 years of experience working in the ICU. Four major themes emerged from the interviews, namely: (1) the work is oriented towards life-threatening emergencies, technical procedures and burdensome care; (2) a range of specific criteria and circumstances influence the decisions to admit patients to ICU; (3) there are significant organisational, physical and psychological repercussions associated with a non-beneficial stay in the ICU; (4) respondents made some proposals for improvements to the patient care pathway.

CONCLUSION

Nursing staff have a similar perception to physicians regarding admission decisions and non-beneficial ICU stays. The possibility of future ICU admission needs to be anticipated, discussed systematically with patients and integrated into healthcare goals that are consistent with the patient's wishes and preferences, in multi-professional collaboration including nursing and medical staff.

Futility and Shared Decision-Making

Medical futility is an ancient and yet consistent challenge in clinical medicine. The means of balancing conflicting priorities and stakeholders' preferences has changed as much as the science that powers the understanding and treatment of disease. The introduction of patient self-determination and choice in medical decision-making shifted the locus of power in the physician-patient relationship but did not obviate the physician's responsibilities to provide benefit and prevent harm. As we have refined the process in time, new paradigms, specialists, and tools have been developed to help navigate the ever-changing landscape.

Disparities in Unilateral Do Not Resuscitate Order Use During the COVID-19 Pandemic

OBJECTIVES

A unilateral do-not-resuscitate (UDNR) order is a do-not-resuscitate order placed using clinician judgment which does not require consent from a patient or surrogate. This study assessed how UDNR orders were used during the COVID-19 pandemic.

DESIGN

We analyzed a retrospective cross-sectional study of UDNR use at two academic medical centers between April 2020 and April 2021.

SETTING

Two academic medical centers in the Chicago metropolitan area.

PATIENTS

Patients admitted to an ICU between April 2020 and April 2021 who received vasopressor or inotropic medications to select for patients with high severity of illness.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The 1,473 patients meeting inclusion criteria were 53% male, median age 64 (interquartile range, 54-73), and 38% died during admission or were discharged to hospice. Clinicians placed do not resuscitate orders for 41% of patients ( n = 604/1,473) and UDNR orders for 3% of patients ( n = 51/1,473). The absolute rate of UDNR orders was higher for patients who were primary Spanish speaking (10% Spanish vs 3% English; p ≤ 0.0001), were Hispanic or Latinx (7% Hispanic/Latinx vs 3% Black vs 2% White; p = 0.003), positive for COVID-19 (9% vs 3%; p ≤ 0.0001), or were intubated (5% vs 1%; p = 0.001). In the base multivariable logistic regression model including age, race/ethnicity, primary language spoken, and hospital location, Black race (adjusted odds ratio [aOR], 2.5; 95% CI, 1.3-4.9) and primary Spanish language (aOR, 4.4; 95% CI, 2.1-9.4) had higher odds of UDNR. After adjusting the base model for severity of illness, primary Spanish language remained associated with higher odds of UDNR order (aOR, 2.8; 95% CI, 1.7-4.7).

CONCLUSIONS

In this multihospital study, UDNR orders were used more often for primary Spanish-speaking patients during the COVID-19 pandemic, which may be related to communication barriers Spanish-speaking patients and families experience. Further study is needed to assess UDNR use across hospitals and enact interventions to improve potential disparities.

Using a Mediator's Toolbox: Reducing Clinical Conflict by Learning to Reconceive the "Difficult" Patient or Family

Introduction

Given the prevalence of conflict between physicians and patients and families, it is crucial that trainees build the skills to manage clinical conflict. Mediators employ an approach that can be applied to clinical encounters to prevent conflicts from escalating. This workshop introduced trainees to techniques commonly used by mediators to manage disputes.

Methods

Medical students in a virtual workshop (cohort A) and clinical fellows in an in-person workshop (cohort B) were presented with a mediator's approach to interpreting patient and family behavior viewed as challenging. Trainees were introduced to two specific techniques designed to facilitate the resolution of clinical conflict. After an interactive large-group discussion of each method, small groups practiced applying the technique to a sample clinical case. Finally, participants completed an assessment of their perception of the workshop's effectiveness.

Results

In early 2022, 15 medical students (cohort A) participated in a virtual workshop and 10 clinical fellows (cohort B) participated in an in-person workshop on clinical conflict management. Eight medical students from cohort A completed the postworkshop assessment (response rate: 53%); six clinical fellows from cohort B completed the assessment (response rate: 60%). Cohort A gave the workshop an overall evaluation of 4.6 out of 5.0; cohort B gave the workshop an overall score of 4.7 out of 5.0.

Discussion

In both the virtual platform and the traditional in-person format, this workshop introduces a set of tools for navigating bedside conflicts with patients and their families that participants believed would better prepare them for such challenging interactions.

Transforming Moral Suffering by Cultivating Moral Resilience and Ethical Practice

Ethical challenges are inherent in nursing practice. They affect patients, families, teams, organizations, and nurses themselves. These challenges arise when there are competing core values or commitments and diverse views on how to balance or reconcile them. When ethical conflict, confusion, or uncertainty cannot be resolved, moral suffering ensues. The consequences of moral suffering in its many forms undermine safe, high-quality patient care, erode teamwork, and undermine well-being and integrity. My experience as a nurse in the pediatric intensive care unit and later as a clinical nurse specialist in confronting these moral and ethical challenges has been the foundation of my program of research. Together we will explore the evolution of our understanding of moral suffering-its expressions, meanings, and consequences and attempts to measure it. Moral distress, the most described form of moral suffering, took hold within nursing and slowly within other disciplines. After 3 decades of research documenting the existence of moral distress, there were few solutions. It was at this juncture that my work pivoted toward exploring the concept of moral resilience as a means for transforming but not eliminating moral suffering. The evolution of the concept, its components, a scale to measure it, and research findings will be explored. Throughout this journey, the interplay of moral resilience and a culture of ethical practice were highlighted and examined. Moral resilience is continuing to evolve in its application and relevance. Many vital lessons have been learned that can inform future research and guide interventions to harness the inherent capabilities of clinicians to restore or preserve their integrity and to engage in large-scale system transformation.

From Bridge to Destination? Ethical Considerations Related to Withdrawal of ECMO Support over the Objections of Capacitated Patients

Extracorporeal membrane oxygenation (ECMO) is typically viewed as a time-limited intervention-a bridge to recovery or transplant-not a destination therapy. However, some patients with decision-making capacity request continued ECMO support despite a poor prognosis for recovery and lack of viability as a transplant candidate. In response, critical care teams have asked for guidance regarding the ethical permissibility of unilateral withdrawal over the objections of a capacitated patient. In this article, we evaluate several ethical arguments that have been made in favor of withdrawal, including distributive justice, quality of life, patients' rights, professional integrity, and the Equivalence Thesis. We find that existing justifications for unilateral withdrawal of ECMO support in capacitated patients are problematic, which leads us to conclude that either: (1) additional ethical arguments are necessary to defend this approach or (2) the claim that it is not appropriate to use ECMO as a destination therapy should be questioned.

Coaching doctors to improve ethical decision-making in adult hospitalised patients potentially receiving excessive treatment: Study protocol for a stepped wedge cluster randomised controlled trial

BACKGROUND

Fast medical progress poses a significant challenge to doctors, who are asked to find the right balance between life-prolonging and palliative care. Literature indicates room for enhancing openness to discuss ethical sensitive issues within and between teams, and improving decision-making for benefit of the patient at end-of-life.

METHODS

Stepped wedge cluster randomized trial design, run across 10 different departments of the Ghent University Hospital between January 2022 and January 2023. Dutch speaking adult patients and one of their relatives will be included for data collection. All 10 departments were randomly assigned to start a 4-month coaching period. Junior and senior doctors will be coached through observation and debrief by a first coach of the interdisciplinary meetings and individual coaching by the second coach to enhance self-reflection and empowering leadership and managing group dynamics with regard to ethical decision-making. Nurses, junior doctors and senior doctors anonymously report perceptions of excessive treatment via the electronic patient file. Once a patient is identified by two or more different clinicians, an email is sent to the second coach and the doctor in charge of the patient. All nurses, junior and senior doctors will be invited to fill out the ethical decision making climate questionnaire at the start and end of the 12-months study period. Primary endpoints are (1) incidence of written do-not-intubate and resuscitate orders in patients potentially receiving excessive treatment and (2) quality of ethical decision-making climate. Secondary endpoints are patient and family well-being and reports on quality of care and communication; and clinician well-being. Tertiairy endpoints are quantitative and qualitative data of doctor leadership quality.

DISCUSSION

This is the first randomized control trial exploring the effects of coaching doctors in self-reflection and empowering leadership, and in the management of team dynamics, with regard to ethical decision-making about patients potentially receiving excessive treatment.

Ethical Considerations in Critically Ill Neonatal and Pediatric Patients

The care of critically ill neonates and pediatric patients can be particularly emotionally and ethically challenging. Emerging evidence suggests that we can improve the patient, family, and care team experience in the critical care setting through a better understanding and application of ethical frameworks and communication strategies. We conducted a multidisciplinary panel session at the American Academy of Pediatrics National Conference and Exhibition in the fall of 2022 wherein we explored a myriad of ethical and communication considerations in this unique patient population, with congenital diaphragmatic hernia (CDH) as the congenital anomaly/disease framework. In this review, we will cover state of the art topics in ethics, communication, and palliative care including basic terminology, communication strategies such as trauma-informed communication, establishing/evolving goals of care, futility, medically inappropriate treatment, ethical frameworks, parental discretion, establishing milestones, internal/external intentions, and re-direction of care. These topics will be helpful to many specialties who are involved in the care of critically ill neonates and children including maternal fetal medicine, pediatrics, neonatology, pediatric critical care, palliative care, and pediatric surgery, along with the pediatric surgical subspecialties. We use a theoretical CDH case as an example and include the live audience responses from the interactive session. This primer provides overarching educational principles, as well as practical communication concepts, that can cultivate compassionate multidisciplinary teams, equipped to optimize family-centered, evidence-based compassionate communication and care.

Early Guided Palliative Care Communication for Patients With COVID-19 Receiving ECMO

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) combined with COVID-19 presents challenges (eg, isolation, anticipatory grief) for patients and families.

OBJECTIVE

To (1) describe characteristics and outcomes of patients with COVID-19 receiving ECMO, (2) develop a practice improvement strategy to implement early, semistructured palliative care communication in ECMO acknowledgment meetings with patients' families, and (3) examine family members' experiences as recorded in clinicians' notes during these meetings.

METHODS

Descriptive observation of guided, in-depth meetings with families of patients with COVID-19 receiving ECMO, as gathered from the electronic medical record of a large urban academic medical center. Most meetings were held within 3 days of initiation of ECMO.

RESULTS

Forty-three patients received ECMO between March and October 2020. The mean patient age was 44 years; 63% of patients were Hispanic/Latino, 19% were Black, and 7% were White. Documentation of the ECMO acknowledgment meeting was completed for 60% of patients. Fifty-six percent of patients survived to hospital discharge. Family discussions revealed 7 common themes: hope, reliance on faith, multiple family members with COVID-19, helping children adjust to a new normal, visitation restrictions, gratitude for clinicians and care, and end-of-life discussions.

CONCLUSION

Early and ongoing provision of palliative care is feasible and useful for highlighting a range of experiences related to COVID-19. Palliative care is also useful for educating patients and families on the benefits and limitations of ECMO therapy.

Off the Beaten Path: Caring for People Engaging in Potentially Unsafe Low Evidence Therapies

Palliative care clinicians regularly care for patients with serious illnesses, many of whom are engaging in the use of complementary and alternative medicine (CAM) either alone or along with conventional medical therapies. A subset of these patients may be engaging in therapies that have little or no evidence for efficacy and carry significant potential risks to their health. These therapies, however, may carry a great deal of significance for the patient and family for whom conventional medicine has failed or is otherwise deemed untenable. Dismissing such therapies as "quackery" risks alienating patients and damaging or even severing a therapeutic relationship. When faced with patients who are engaging in potentially unsafe low-evidence therapies (PULETs), clinicians themselves may experience a great deal of moral distress when deciding how to balance supporting the hope PULETs may represent with the principles of nonmaleficence and autonomy. In this article, we will review the definition of PULETs and distinguish them from most CAM therapies. Drawing upon existing writings in the CAM literature, we will then review a framework to evaluate the relative risk/benefit ratio of such therapies followed by a review of the ethical and legal aspects of care. Finally, utilizing existing principles and tools in emotion-based communication, we present a communication approach to foster continued collaboration and care for patients who engage in PULETs.

Ethical Issues in Using Behavior Contracts to Manage the "Difficult" Patient and Family

Long used as a tool for medical compliance and adhering to treatment plans, behavior contracts have made their way into the in-patient healthcare setting as a way to manage the "difficult" patient and family. The use of this tool is even being adopted by healthcare ethics consultants (HECs) in US hospitals as part of their work in navigating conflict at the bedside. Anecdotal evidence of their increasing popularity among clinical ethicists, for example, can be found at professional bioethics meetings and conversations and idea-sharing among practitioners on HEC social media. While there are a handful of papers gesturing toward a bioethical critique of behavior contracts of various types, the use of behavior contracts in the context of interpersonal conflict has not been vetted by bioethicists to determine their ethical legitimacy or efficacy. In this paper, we highlight a set of ethical concerns that we believe must be addressed before continuing or widespread implementation of behavior contracts to manage the "difficult" patient or family.

Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians' beliefs

INTRODUCTION

Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs.

METHODS

Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians.

RESULTS

Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient's wishes would help avoid these conflicts.

CONCLUSION

Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.

End of Life: What Is the Anesthesiologist's Role?

Anesthesiologists receive extensive training in the area of perioperative care and the specialized skills required to maintain life during surgery and complex procedures. Integrated into almost every facet of contemporary medicine, they interact with patients at multiple stages of their health care journeys. While traditionally thought of as the doctors best equipped to save lives, they may also be some of the best doctors to help navigate the chapters at the end of life. Successfully navigating end-of-life care, particularly in the COVID-19 era, is a complicated task. Competing ethical principles of autonomy and nonmaleficence may often be encountered as sophisticated medical technologies offer the promise of extending life longer than ever before seen. From encouraging patients to actively engage in advance care planning, normalizing the conversations around the end of life, employing our skills to relieve pain and suffering associated with dying, and using our empathy and communication skills to also care for the families of dying patients, there are many ways for the anesthesiologist to elevate the care provided at the end of life. The aim of this article is to review the existing literature on the role of the anesthesiologist in end-of-life care, as well as to encourage future development of our specialty in this area.