End of Life and Palliative Care in ICU

I: You are the ICU registrar on a day shift looking after patient who was admitted to ICU 11 days ago with pneumonia and sepsis.  

S: Nurses are concerned the patient has continued to deteriorate over the last 48 hours 

B: 52M, known history of alcoholic liver disease admitted 11 days ago with pneumonia and sepsis. This episode has provoked acute on chronic liver failure and the tertiary centre is unable to offer any treatment options. For the last 6 days the patient has been on multiple organ support – RRT, vasopressors and high flow oxygen and has developed hepatic encephalopathy. In view of this, he is DNACPR and not for intubation and ventilation. Over the last 48 hours he has continued to deteriorate with worsening acidosis and rising cardiovascular and respiratory support requirements.  

A: Hypotensive and hypoxic with worsening GCS  

R: Called for help 

• Initially A own, B sats 90%, high flow oxygen – Fio2 0.8, flow 50L/min, bilateral air entry, RR 42 C HR 98 bpm SR, BP 80/60, D E2V2M5 

• Progression will depend on the actions taken by the candidates: 

• Candidates should recognise that ceilings of treatment have been reached 

• If the candidate does not recognise that ceilings of treatment has been reached, the patient should continue to deteriorate slowly and nursing staff will be hesitant to increase any support as it has been capped. Nursing staff can helpfully suggest starting end of life care or offering to call palliative care.  

• Appropriate communication with the family member and the patient should be the priority.  

• Initial settings:   
  • SpO2  90% on FiO2 0.8, flow 50L/min 
  • Bilateral air entry, RR 42 
  • HR 98 pm, SR 
  • BP 80/60 
  • E2V2M5, T 37.2, eyes closed 

• Progress to if not recognised: sata 88% on FiO2 0.8, flow 50L/min, RR 50, HR 110, BP 70/40, E1V1M2                            

• If unrecognised- the family member can prompt by asking what is going on and demanding an explanation.  

Bedside Nurse 1: 

• You are a senior ITU nurse 

• You are looking after 52 year old with known chronic liver disease who you recognise is approaching the end of their life.  

• You want the doctor to prescribe anticipatory medication and speak to the patient’s family. You know the patient well and want to ensure they die peacefully.  

• You don’t want to tell the doctor what to do but will push gently if they want to escalate vasopressors or FiO2 beyond the agreed ceilings of care.  

• You take direction well, and can perform tasks asked if you in a timely fashion 

Bedside Nurse 2 (ideally, however, the simulation can be run with one bedside nurse): 

• You are a new starter; this is your second day in ITU 

• You are quite startled when asked questions/given directions, requiring instructions to be repeated to you 

• If the candidate names equipment using technical terms, then you inform them that you don’t know what that is  

• You are keen to help, but are unwilling to do anything beyond your skill set 

Family member: 

• You were aware that the situation was dire and that your relative was very unwell, but you are still shocked that it is now progressing to death. You are not angry, but have all the expected questions and worries regarding how long it will take, will there be pain, suffering, etc.  

If asked for help, ITU consultant available with some delay.  

HiLLO: 6