Critical Care · Year 4 · from Critical Care
Case 1: Goals of Care and Withdrawal of Life-Sustaining Treatment
Clinical Image
Source: Wikimedia Commons - Hospital - CC BY-SA 4.0
Case Presentation
An 82-year-old woman with metastatic pancreatic cancer, diabetes, and heart failure is admitted to the ICU with septic shock from cholangitis. She is intubated for respiratory failure and requires norepinephrine at 0.3 mcg/kg/min. Her oncologist confirms there are no further cancer-directed treatment options. On ICU day 3, despite source control with biliary stent placement and broad-spectrum antibiotics, she remains ventilator-dependent with worsening multi-organ failure (creatinine rising to 4.2 mg/dL, lactate persistently greater than 4 mmol/L). The ICU team initiates a family meeting using a structured approach: they assess the family's understanding (the husband believes she "just needs to fight through this"), provide honest medical update about poor prognosis with less than 10% chance of surviving to hospital discharge, explore the patient's values (she had previously said she "never wanted to be on machines"), and make a recommendation that continued aggressive treatment would not be consistent with her values or likely to provide meaningful benefit. Using the NURSE technique, the physician names the emotion ("I can see how devastating this is"), expresses understanding ("This is incredibly difficult to face"), and offers support ("We will continue to care for her no matter what you decide"). The family, after time to process, agrees to transition to comfort-focused care. Vasopressors are discontinued, and she is terminally extubated with morphine and midazolam for comfort. She dies peacefully with her family present 2 hours later.
Key Learning Points
- Goals of care discussions should explore patient values before making recommendations; the key question is "what would the patient want?" not "what do you want us to do?"
- The SPIKES protocol (Setting, Perception, Invitation, Knowledge, Emotions, Strategy/Summary) structures difficult conversations
- Withdrawal of life-sustaining treatment is ethically equivalent to withholding; both allow the underlying disease to cause death
- Terminal extubation and terminal weaning are both acceptable approaches; pre-medication with opioids and benzodiazepines ensures comfort during the process