title: Care near the end-of-life in critically ill patients: a North American perspective.
abstract: OBJECTIVE
  End-of-life care for critically ill patients has emerged as an area in which significant quality improvement is possible. In this article, we present a North American perspective on recent research and quality improvement initiatives in this field.
  
  
  RESULTS
  Some of the most important recent developments in end-of-life care in the intensive care unit concern physician-patient-family communication. There is consensus between North American and European professional societies that a shared approach to decision-making by physicians and family members is optimal. The shared decision approach demands that physicians not only skillfully elicit the patient's treatment preferences but also effectively inform the family of the patient's clinical condition and prognosis. Moreover, the ultimate responsibility for end-of-life treatment decisions is shared between the physician and the patient or family.
  
  
  CONCLUSIONS
  This update presents a North American perspective on six topics of particular importance to end-of-life care in the intensive care unit: (a) The role of advance directives, (b) shared decision-making and the role of the family, (c) conflict and futility in the intensive care unit, (d) cultural aspects of end-of-life care, (e) multidisciplinary care in the intensive care unit, and (f) future directions for improving end-of-life care in the intensive care unit.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, University of California, San Francisco School of Medicine, San Francisco, California 94143-0903, USA. dwhite@medicine.ucsf.edu
authors.forename: Douglas B
authors.initials: DB
authors.lastname: White
authors.forename: J Randall
authors.initials: JR
authors.lastname: Curtis
mesh_terms: D016223:Advance Directives; D003657:Decision Making; D006801:Humans; D007362:Intensive Care Units; D009656:North America; D010348:Patient Care Team; D011786:Quality Control; D013727:Terminal Care / Q000458:organization & administration*