title: Implementation of ICU palliative care guidelines and procedures: a quality improvement initiative following an investigation of alleged euthanasia.
abstract: Ethical conflicts are commonly encountered in the course of delivering end-of-life care in the ICU. Some ethical concerns have legal dimensions, including concerns about inappropriate hastening of death. Despite these concerns, many ICUs do not have explicit policies and procedures for withdrawal of life-sustaining treatments. We describe a US Office of Inspector General (OIG) investigation of end-of-life care practices in our ICU. The investigation focused on care delivered to four critically ill patients with terminal diseases and an ICU nurse's concern that the patients had been subjected to euthanasia. The OIG investigation also assessed the validity of allegations that patient flow in and out of our ICU was inappropriately influenced by scheduled surgeries and that end-of-life care policies in our ICU were not clear. Although the investigation did not substantiate the allegations of euthanasia or inappropriate ICU patient flow, it did find that the policies that discuss end-of-life care issues were not clear and allowed for wide-ranging interpretations. Acting on the OIG recommendations, we developed a quality improvement initiative addressing end-of-life care in our ICU, intended to enhance communication and understanding about palliative care practices in our ICU, to prevent ethical conflicts surrounding end-of-life care, and to improve patient care. The initiative included the introduction of newly developed ICU comfort care guidelines, a physician order set, and a physician template note. Additionally, we implemented an educational program for ICU staff. Staff feedback regarding the initiative has been highly favorable, and the nurse whose concerns led to the investigation was satisfied not only with the investigation but also the policies and procedures that were subsequently introduced in our ICU.
authors.affiliation: Medical Service, Pulmonary and Critical Care Medicine Section, US Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA. Electronic address: ware.kuschnermd@va.gov.
authors.forename: Ware G
authors.initials: WG
authors.lastname: Kuschner
authors.affiliation: Geriatrics and Extended Care Service, US Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA.
authors.forename: David A
authors.initials: DA
authors.lastname: Gruenewald
authors.affiliation: US Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
authors.forename: Nancy
authors.initials: N
authors.lastname: Clum
authors.affiliation: Medical Service, US Department of Veterans Affairs New York Harbor Health Care System, Brooklyn, NY.
authors.forename: Alice
authors.initials: A
authors.lastname: Beal
authors.affiliation: Medical Service and Chief of Staff Office, US Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
authors.forename: Stephen C
authors.initials: SC
authors.lastname: Ezeji-Okoye
mesh_terms: D000368:Aged; D003422:Critical Care; D005065:Euthanasia; D006801:Humans; D008297:Male; D008875:Middle Aged; D009294:Narcotics / Q000008:administration & dosage; D010102:Oxygen Inhalation Therapy; D010166:Palliative Care; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care; D028761:Withholding Treatment
chemical_list: D009294:Narcotics