What are the key indicators for initiating end-of-life discussions for patients in critical care settings?

Key indicators for initiating end-of-life discussions with patients in critical care settings include:

• Progressive deterioration: Day-by-day or rapid decline in condition, including reduced mobility, increasing weakness, fatigue, and weight loss without apparent cause ².
• Physiological signs of terminal phase: Changes such as agitation, Cheyne-Stokes breathing, deterioration in consciousness, mottled skin, noisy respiratory secretions, peripheral cyanosis, and altered breathing patterns ²,³.
• Functional decline: Reduced ability to communicate, social withdrawal, delirium, bed-bound status, difficulty taking oral medication or fluids ².
• Recognition of prognosis: When it is estimated that the patient may be entering the last days or months of life, often guided by tools like the Prognostic Indicator Guidelines and the question, “Would you be surprised if this patient were to die in the next 6 to 12 months?” ².
• Patient and family cues: Expressions of awareness or realization of dying, concerns about prognosis, or requests for information about future care ²,³.
• Clinical judgment and multidisciplinary assessment: Integration of clinical signs, symptoms, medical history, and patient goals to identify when the patient is nearing end of life ³.

Initiating discussions should be sensitive to the patient’s cognitive status, communication needs, cultural and spiritual preferences, and readiness to receive information about prognosis ²,³. These conversations should include the patient and those important to them, ensuring shared decision-making and advance care planning ¹,²,³.