In reply to the question: “Are we really playing together in the same team?”

Dear Editor,

Following mindful reading of the study by Lomero-Martínez et al.¹ published in your journal, we would like to congratulate the authors for their work and also offer some considerations on the same.

Firstly, we have been speaking for some time about limitation of life-sustaining treatment (LLST) in Intensive Care Medicine and possibly the more extended term of limitation of therapeutic efforts (LTE), and the term which currently tends to be adopted of the adequacy of life-sustaining treatment efforts (ALST).² It is possible that with the technification of medicine and the measures that can be applied to treat our patients, doctors and all other healthcare staff have become aware of the need to customise the measures applied to each patient, to avoid therapeutic obstination, and when death may not be avoided, to accompany the patient and guarantee them a dignified death.³

From their results the authors also concluded that the patients feel excluded from protocol development and from decision-making processes in the LLST. In this sense, we, the undersigned, as workers in a multipurpose 12 cubicle ICU, have been dealing with this difficulty for some time. To tackle the problem and provide the best care for our patients, our optimisation strategies began with initiating a combined physician-nurse ICU round patient review during the mornings where these decisions were taken jointly and information was communicated more easily between all healthcare professionals.

The withdrawal of mechanical ventilation (MV) is particularly outstanding here as a measure of LLST, having been described in the past as the most difficult treatment for the medical team to withdraw.⁴ From the article we understand that among the nurses 36.5% would not be in favour of MV removal, but this percentage drops to 12.9% for the physicians. Studies confirm that in up to 54% of cases this is done with the intention of accelerating death and not wishing to prolong life.⁴ Perhaps the origin of the ethical conflict suggested by the removal of MV would be to consider it in this way, whilst in the majority of cases its removal occurs after a period of treatment and is done after confirming that the measures implemented are not useful, and they are therefore futile.

Lastly, it is no less certain that on no few occasions the decisions of LLST derive from the futility of treatments which have already been established for our patients or from future therapies to be initiated.⁵ At this point, we consider it inexcusable that evaluation of their futility, whether this be from a physiopathological, probabilistic or qualitative viewpoint, should fall on our medical staff. Our observation is mainly based on two very clear criteria. Firstly, the continuous care which the doctor in charge of the patient undertakes under normal circumstances and which on many occasions (at least in our unit), due to issues involving working hours, the nurses cannot perform. Secondly, without wishing to disrespect the work of any professional, we consider that responsibility for updating and obtaining knowledge about new therapies or diagnostic tests which will often influence many decisions regarding futility should fall on the personnel who have been trained for this purpose. In this context, this would be the medical staff.

To conclude, our experience of a combined physician-nurse ICU round patient review has helped to improve decision-making in LLST situations. The proposal of medical futility in treatments, assessment and follow-up of these therapies from the nurse and the communication of emotions, feelings and assessments from family members who are near the patient are key and must be taking into consideration by us in improving patient care.

Financing

No financing was received for this document.

Conflict of interests

All the authors have no conflict of interests to declare.