Review Article| Volume 20, ISSUE 3, P505-523, July 2004

Ethics and palliative care consultation in the intensive care unit

      Mr. Smith is a ventilator- and feeding tube-dependent 76-year-old Black male suffering from advanced Parkinson's-like symptoms. Before his admission to the intensive care unit (ICU), Mr. Smith developed aspiration-induced pneumonia, resulting in placement on vent support and the administration of tube feeding. After 7 weeks in the medical ICU, he is not responding well to medication and his condition is deteriorating. Mr. Smith has moderate to severe dementia, and periodically lapses in and out of consciousness. Mr. Smith's wife of 5 years has been actively involved in care decisions, as has his 27-year-old daughter from a previous marriage. Mr. Smith also has a 46-year-old son who lives out of state, and has not been reachable despite numerous attempts by family and social work. Mr. Smith is faced with the prospect of placement in a skilled nursing facility, with continued tube feeding and ventilator support, or withdrawal of life support in the ICU, with the likelihood of imminent death. Mr. Smith periodically appears to be uncomfortable, as he sometimes winces and grimace when suctioned. Mr. Smith's wife and daughter both want continued aggressive care in the ICU setting, resisting nursing home placement. The ICU attendant, Dr. Jones, thinks that Mr. Smith should be made do-not-resusitate, and that all technological support should be withdrawn. He believes that the focus of care should be on comfort. Dr. Jones and Mrs. Smith have had several tense discussions about this, and are now barely speaking to each other.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribers receive full online access to your subscription and archive of back issues up to and including 2002.

      Content published before 2002 is available via pay-per-view purchase only.


      Subscribe to Critical Care Clinics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lo B
        Answers and questions about ethics consultation.
        JAMA. 2003; 290: 1208-1210
        • La Puma J
        • Stocking C.B
        • Silverstein M.D
        • DiMartini A
        • Siegler M
        An ethics consultation service in a teaching hospital: utilization and evaluation.
        JAMA. 1988; 260: 808-811
        • American Society for Bioethics and Humanities
        • SHHV-SBC Task Force on Standards for Bioethics Consultation
        Core competencies for ethics consultation: The Report of the American Society for Bioethics and Humanities. American Society for Bioethics and Humanities, Glenview (IL)1998: 3-7
        • Fletcher J.C
        • Hoffmann D.E
        Ethics committees: time to experiment with standards.
        Ann Intern Med. 1994; 120: 335-338
        • Aulisio M.P
        • Ethics committees and consultation
        Encyclopedia of bioethics. 3rd edition. Macmillan Reference USA, New York2003
        • Pence G.E
        Classic cases in medical ethics: accounts of cases that have shaped medical ethics, with philosophical, legal, and historical backgrounds. 4th edition. McGraw-Hill, Boston (MA): New York2003
        • Youngner S.J
        • Jackson D.L
        • Coulton C
        • Juknialis B
        • Smith E.M
        A national survey of hospital ethics committees.
        Crit Care Med. 1983; 11: 902-905
        • Fleetwood J.E
        • Arnold R.M
        • Baron R.J
        Giving answers or raising questions: the problematic role of institutional ethics committees.
        J Med Ethics. 1989; 15: 137-142
      1. Baby Doe, In re, 291 S.C. 389, 353 S.E.2d 877 (S.C. 1987)

      2. In Re Conroy, 98 N.J. 321, 486, A2d 1209 (N.J. 1985)

      3. Bouvia v. Superior Court Ca., 179 Cal.App.3d. 1127, 225 Cal.Rptr. 297 (CalApp. 2 Dist. 1987)

      4. Cruzan v. Director, Missouri Dept of Health, 497 US, 261, 110 S.Ct., 28411 111. L.Ed. 1990;2d: 224

        • Schneiderman L.J
        • Jecker N
        Futility in practice.
        Arch Intern Med. 1993; 153: 437-441
        • Youngner S.J
        Medical futility.
        Crit Care Clin. 1996; 12: 165-178
      5. R. The Accreditation Manual of the Joint Commission on the Accreditation of Healthcare Organizations; 1993. p. 9

        • McGee G
        • Caplan A.L
        • Spanogle J.P
        • Asch D.A
        A national study of ethics committees.
        Am J Bioethics. 2001; 1: 60-64
      6. Fox E. Ethics consultation in US hospitals: a national study and its implications. Abstract and Presentation at the Annual Meeting of the American Society for Bioethics and Humanities, Baltimore, MD; October 2002

      7. Foley K.M Hendin H The case against assisted suicide: for the right to end of life care. Johns Hopkins University Press, Baltimore (MD)2002
        • Tolle S.W
        Changing end-of-life planning: The Oregon experience.
        J Palliat Med. 2002; 5: 311-318
        • SUPPORT Principal Investigators
        A controlled trial to improve care for seriously ill hospitalized patients.
        JAMA. 1995; 274: 1591-1598
      8. Last Acts.
        Precepts of Palliative Care. 1998; (See)
      9. A death of one's own; on our own terms; Moyers on dying. Public Affairs TV, Princeton (NJ)2000
        • Pantilat S
        • Billings J.A
        Prevalence and structure of palliative care services in california hospitals.
        Arch Intern Med. 2003; 163: 1084-1088
        • Billings J.A
        • Pantilat S
        Survey of palliative care programs in United States teaching hospitals.
        J Palliat Med. 2001; 4: 309-314
        • Knaus W.A
        • Wagner D.P
        • Zimmerman J.E
        • Draper E.A
        Variations in mortality and length of stay in intensive care units.
        Ann Intern Med. 1993; 118: 753-761
        • Robert J
        • Baranowski-Birkmeier T
        • O'Donnell J.B
        Advance directives in the medical intensive care unit of a communicty teaching hospital.
        Chest. 1995; 107: 752-756
        • Teno J
        • Fisher E
        • Hamel M.B
        • Wu A
        • Murphy D.J
        • Wenger N.S
        • et al.
        Decision-making and outocmes of prolonged ICU stays in seriously ill patients.
        J Am Geriatr Soc. 2000; 48: S70-S74
        • Lipsett P.A
        • Swoboda S.M
        • Kickerson J
        • Ylitalo M
        • Gordon T
        • Breslow M
        • et al.
        Survival and functional outcome after prolonged intensive care unit stay.
        Ann Surg. 2000; 231: 262-268
        • Staudinger T
        • Stoiser B
        • Mullner M
        • Locker G
        • Laczika K
        • Knapp S
        • et al.
        Outcome and prognostic factors in critically ill cancer patients admitted to the intensive care unit.
        Crit Care Med. 2000; 28: 1322-1328
        • SUPPORT Principal Investigators
        A controlled trial to improve care for seriously ill hospitalized patients.
        JAMA. 1995; 274: 1591-1598
        • La Puma J
        Consultations in clinical ethics—issues and questions in 27 cases.
        West J Med. 1987; 146: 633-637
        • La Puma J
        • Stocking C.B
        • Silverstein M.D
        • DiMartini A
        • Siegler M
        An ethics consultation service in a teaching hospital: utilization and evaluation.
        JAMA. 1988; 260: 808-811
        • La Puma J
        • Stocking C.B
        • Darling C.M
        • Siegler M
        Community hospital ethics consultation: evaluation and comparison with a university hospital service [see comments] [comments in Am J Med 1992;92(4):343–5].
        Am J Med. 1992; 92: 346-351
        • Danis M
        The promise of proactive ethics consultation.
        Crit Care Med. 1998; 26: 203-204
        • Schneiderman L
        • Gilmer T
        • Teetzel H
        • et al.
        Effects of ethcis consultations on nonbeneficial life-sustaining treatments in the intensive care settting.
        JAMA. 2003; 290: 1166-1172
        • Dowdy M.D
        • Robertson C
        • Bandera J.A
        A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay.
        Crit Care Med. 1998; 26: 252-259
        • Schneiderman L
        • Gilmer T
        • Teetzel H
        Impact of ethics consultations in the intensive care setting: a randomized, controlled study.
        Crit Care Med. 2000; 28: 3920-3924
        • Yen B
        • Schneiderman L
        Impact of pediatric ethics consultations on patients, families, social workers and physician.
        J Perinatol. 1999; 19: 373-378
        • Schneiderman L.J
        • Gilmer T
        • Teetzel H.D
        • Dugan D.O
        • Blustein J
        • Crawford R
        • et al.
        Effect of ethics consultation on nonbeneficial life-sustaining treatments in the intensive care setting.
        JAMA. 2003; 290: 1166-1172
        • Lilly C.M
        • De Meo D.L
        • Sonna L.A
        • et al.
        An intensive communication intervention for the critically ill.
        Am J Med. 2000; 109: 469-475
        • Lilly C.M
        • Sonna L.A
        • Haley K.J
        • Massaro A.F
        Intensive communication: four-year follow-up from a clinical practice study.
        Crit Care Med. 2003; 31: 394-400
        • Campbell M
        • Guzman J
        Impact of a proactive approach to improve end-of-life care in a medical ICU.
        Chest. 2003; 123: 266-271
        • Forrow L
        • Arnold R.M
        • Parker L.S
        Preventive ethics: expanding the horizons of clinical ethics.
        J Clin Ethics. 1993; 4: 287-294
        • Aulisio M.P
        Ethics consultation: is it enough to mean well?.
        HEC Forum. 1999; 11: 208-217
        • Aulisio M.P
        Meeting the need: ethics consultation in health care today.
        in: Aulisio M Arnold R Youngner S Ethics consultation: from theory to practice. The Johns Hopkins University Press, Baltimore (MD)2003: 1-22
        • Ury W.A
        • Rahn M
        • Tolentino V
        • et al.
        Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents?.
        J Gen Intern Med. 2002; 17: 625-631
        • Jack B
        • Hillier V
        • Williams A
        • Oldham J
        Hospital based palliative care teams improve the symptoms of cancer patients.
        Pallat Med. 2003; 17: 498-503
        • Higginson I.J
        • Finlay I.G
        • Goodwin D.M
        • Cook A.M
        • Hood K
        • Edwards A.G.K
        • Douglas H
        • et al.
        Do hospital-based palliative teams improve care for patients or families at the end of life?.
        J Pain Symptom Manage. 2002; 23: 96-106
        • Higginson I.J
        • Finlay I.G
        • Goodwin D.M
        • Hood K
        • Edwards A.G.K
        • Cook A.M
        • Douglas H.R
        • et al.
        Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers.
        J Pain Symp Manage. 2003; 25: 150-168
        • Walker M.U
        Keeping moral spaces open: new images of ethics consulting.
        Hastings Cent Rep. 1993; 23: 33-40
        • Davies L
        • Hudson L.D
        Why don't physicians use ethics consultation?.
        J Clin Ethics. 1999; 10: 116-125