Table 2 Palliative Care in the ICU

   Good Intensive Care must seek to provide relief of pain and suffering for ALL Intensive Care Unit (ICU) patients, not solely for those for whom death is inevitable. The palliation of dying patients in the ICU is different from palliative care in other settings since the dying process tends to be more dramatic and the time from withholding/withdrawing active disease treatment to death is much shorter. Ensuring good palliative care in the ICU is crucial.

Goals of Palliative Care in the Intensive Care Unit

   The goals of palliative care in the ICU are: 1) relief of pain, 2) relief of agitation and anxiety, 3) relief of dyspnea, 4) psychological and spiritual support of patient and family and, 5) provision of comfort by changing the technological ICU environment to a more comfortable, peaceful one. Patients' wishes, including those expressed by advance directives, must be respected by the medical team.

Difficulties in the Assessment of Pain and Suffering

   Pain and suffering are different. The ability to assess a patient's pain and suffering is crucial, yet these skills are poorly taught, if taught at all. In the Intensive Care Unit, pain assessment is rendered even more difficult by: 1) communication problems imposed by the ICU environment, 2) the severity of illness and the presence of multisystem organ failure, 3) decreased level of consciousness of patients as a result of illness and drugs, 4) our own lack of knowledge/difficulty in interpretation of clinical signs, and, 5) the unreliability of clinical signs. Suffering, because of its even greater individual nature, is harder to assess. Since the assessment of suffering may not be easily amenable to teaching, what must be taught is respect for others' values; values through which individual suffering is perceived. Intensivists need to be aware of the abilities of their ICU staff in assessing and ensuring adequate relief of pain and suffering. Education, research and discussions with family members may be invaluable in improving the abilities of physicians and nurses to determine patient suffering