LAUSR

Past: from defining death to shared decision‐making Three decades ago, we struggled to define death in the face of technology that supported respiratory and cardiovascular function beyond previously imagined boundaries. We had to come to terms with intensive care in relation to the end of life. Initially, a new definition of death, based on brain function, provided a rationale for discontinuing mechanical ventilation and other therapies despite a beating heart and stable hemodynamics [1]. As time went on, we accepted the reality that our own decisions to use, withhold, or withdraw intensive care had life and death consequences. We focused on how those decisions would be made and implemented, seeking a rational and fair process, based on intensive monitoring and sophisticated modeling to predict the patient’s outcome. Palliative care as a field emerged in the 1990s, thrust into national focus by the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (“SUPPORT”) with the aim to improve end-of-life experience for seriously ill patients [2]. The failure of the SUPPORT intervention and, more importantly, the harsh light it shone on the way patients were dying in the ICU and elsewhere, became a call to action. We resolved to relieve the suffering, communicate better with patients and families about goals of care, align treatments more closely with the values and preferences of patients, and limit burdensome therapies. In those early years, the field focused primarily on dying and death. Trigger criteria were created to identify patients at highest mortality risk and engage palliative care specialists [3]. We learned how to “save deaths” as well as save lives—to tell families that their loved ones were approaching the end, maintain comfort while limiting life support, and alleviate our own emotional and moral distress [4–6].