Kuschner Ware G, Gruenewald David A, Clum Nancy, Beal Alice, Ezeji-Okoye Stephen C
Medical Service, Pulmonary and Critical Care Medicine Section, US Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
Geriatrics and Extended Care Service, US Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA.
Chest. 2009 Jan;135(1):26-32. doi: 10.1378/chest.08-1685.
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.
在重症监护病房（ICU）提供临终护理的过程中，经常会遇到伦理冲突。一些伦理问题具有法律层面，包括对不适当加速死亡的担忧。尽管存在这些担忧，但许多重症监护病房并没有关于撤除维持生命治疗的明确政策和程序。我们描述了美国监察长办公室（OIG）对我们重症监护病房临终护理实践的调查。该调查聚焦于为四名患有绝症的重症患者提供的护理，以及一名重症监护病房护士担心这些患者遭受了安乐死。监察长办公室的调查还评估了有关指控的有效性，即进出我们重症监护病房的患者流量受到预定手术的不当影响，以及我们重症监护病房的临终护理政策不明确。尽管调查没有证实安乐死或重症监护病房患者流量不当的指控，但确实发现讨论临终护理问题的政策不明确，且允许有广泛的解释。根据监察长办公室的建议，我们制定了一项质量改进计划，以解决我们重症监护病房的临终护理问题，旨在加强对我们重症监护病房姑息治疗实践的沟通和理解，防止围绕临终护理的伦理冲突，并改善患者护理。该计划包括引入新制定的重症监护病房舒适护理指南、医生医嘱集和医生模板记录。此外，我们为重症监护病房的工作人员实施了一项教育计划。工作人员对该计划的反馈非常积极，引发调查的护士不仅对调查结果满意，也对我们重症监护病房随后出台的政策和程序感到满意。
