“No escalation of treatment” as a routine strategy for decision-making in the ICU: pro

Excerpt

The recent article by Morgan et al. entitled “Defining the practice of ‘no escalation of care’ in ICU” has engendered some controversy along with the editorial that accompanied it [1, 2]. The correct term should be “no escalation of therapy” (NEOT) as stated in the editorial because we always care about the patient. Almost simultaneously Curtis et al. [3] reported an article entitled “The importance of word choice in the care of critically ill patients and their families.” The term “no escalation of treatment” is espoused to be particularly confusing to patients and family and from clinician to clinician and should not be used. The term is not more confusing than many of the other terms used in limitations of therapy. Two of the best examples of confusing terminology are DNR (do not resuscitate) and comfort measures. What is it that we do not resuscitate? Usually we do not resuscitate the patient if they have a cardiac arrest. But do we intubate the patient if they have respiratory failure or do we try to prevent the cardiac arrest with intubation? Do we give antiarrhythmic drugs to prevent cardiac arrest? What if the patient has an MI and simple defibrillation without CPR will reverse the problem and leave no long-term impairment? Curtis also suggests that we should not “break up” the advanced cardiovascular life support (ACLS) into components (chest compressions, drugs, defibrillation, and intubation) [4]. It does not make any sense to be doing chest compression in an unintubated patient or giving drugs but no chest compressions to circulate the drugs. However, these terms mean difference things to different people. Some have suggested do not attempt resuscitation (DNAR) or all but cardiac resuscitation and do not intubate (DNI) as some examples of alternate phrases and abbreviations. Perhaps in some cases we should not use the terms because of the lack of clarity, but we do use these terms. …