[How to report the end-of-life decisions in the clinical record? Proposal of an "ABCD".]

Abstract

Coping with the end of life decision making process in ICU, its complexity adds a challenge for the healthcare team: how to report in the medical record the events and reasoning that led to withholding or withdrawing treatments shifting from intensive to palliative care. Each healthcare team must select the best approach for managing the decision-making process and the necessary rules to ensure a correct clinical history narrative, indicating who must write and what has to be written. Taking into account the team organization, the report may be written not necessarily by the ICU director, but also by a staff physician as a spokesperson in the individual case. Regardless of the variability of each case, four points must be necessarily recorded recalling them with the first four letters of the alphabet (A, B, C, D) for an easier memorization: A= Anamnesis (clinical summary); B= Balancing (remodulation of care); C= Collegiality (sharing of decisions); D= Dialogue (conversation with the patient and/or family members).