Abstract
Background
Neurologically critically ill patients present with unique disease trajectories, prognostic uncertainties, and challenges to end-of-life (EOL) care. Acute brain injuries place these patients at risk for underrecognized symptoms and unmet EOL management needs, which can negatively affect their quality of care and lead to complicated grief in surviving loved ones. To care for patients nearing the EOL in the neurointensive care unit, health care clinicians must consider neuroanatomic localization, barriers to symptom assessment and management, unique aspects of the dying process, and EOL management needs.
Aim
We aim to define current best practices, barriers, and future directions for EOL care of the neurologically critically ill patient.
Key Points:
- Neurological Challenges: Acute brain injuries create barriers to symptom assessment due to altered consciousness, covert consciousness risks, and motor impairments.
- Symptom Management: Neuro-ICU patients require tailored interventions, including opioids for dyspnea, anticonvulsants for seizures, and sedatives for comfort during terminal weaning.
- Family Communication: Goals-of-care discussions and clear explanations of the dying process help reduce anxiety and uncertainty for families.
- Palliative Withdrawal of Mechanical Ventilation (WMV): Strategies like anticipatory dosing of analgesics improve patient comfort and family satisfaction during WMV.
- Bereavement Care: Families need ongoing support before and after death to address grief, with frameworks for communication and access to resources.
- Organ Donation Considerations: Decision-making around organ donation requires adherence to neurological death criteria and sensitivity toward family dynamics.
- Clinician Support: Addressing burnout and emotional distress among neuro-ICU staff through debriefing and self-care strategies is essential for sustainable care.
- Screening Tools: Neuropalliative care would benefit from validated tools tailored to neurological injuries for symptom assessment and management.
- Education and Training: Expanding end-of-life training for neuro-ICU teams enhances clinician competence in delivering high-quality palliative care.
- Research Needs: Developing standardized neuro-specific assessment tools and evaluating interventions’ effectiveness are key areas for future research.
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