Inevitably, ethical dilemmas and end-of-life decisions are issues that need to be faced in the common practice of intensive care units. In this review these dilemmas are approached through the medical ethical issues of patient autonomy, beneficence, non-maleficence and justice. Patient autonomy is further analyzed as opposed to medical paternalism with reference to historical, political, social and legal particularities.
The theoretical background of therapy de-escalation is then analyzed along with the transition from restorative to palliative care.
Informed consent issues are approached with reference to legal as well as to philosophical aspects. Recent evidence is also summarized. Furthermore, beyond its legal aspect, consensus achievement between families and health care practitioners is examined in more detail, through older or more recent philosophical and political approaches.
The practical issues of therapy de-escalation are then presented, either in the form of withholding or that of withdrawal of treatment. The “double effect doctrine” is approached, as the background of differentiation between euthanasia and palliation. Practical issues include end-of-life care protocols implementation, patient and family support and caregivers’ attitudes, objectives and participation in these procedures. Information on patient comfort, mechanical ventilation discontinuation and “terminal weaning” are quoted.
The review concludes that in the difficult and frustrating reality of end-of-life decisions, doctors, nurses and ICU personnel sensitization towards a better understanding of the dying patient’s needs and a more holistic psycho-biological approach, with empathy and patient’s autonomy respect, may contribute in a more serene acceptance of the fact of death.