Background The majority of ICU deaths are preceded by an end-of-life decision.

Aim To discuss the challenges of end-of-life care and use of ACPs in critically ill patients.

Methods Review of relevant literature and personal experience.

Results ACPs apply more to patients with chronic conditions (eg. advanced cancer or progressively debilitating diseases) and are rarely relevant in the ICU setting.

Discussion The more acute the disease, the more difficult it is to determine how an individual would wish to be treated, as he/she is no longer in a position to make decisions. There are many different types of acute, unexpected events and many different processes, and it is not possible to cover every eventuality in one document, whatever its length. Moreover, it is often difficult to predict the likelihood of recovery in these patients. Hence, ACPs do not make sense in the acute setting. One could argue that ACPs may prevent futile therapy, but disproportionate care (a preferred term nowadays) should anyway be avoided in all cases, and there is no need for a document to confirm this. Many consider it preferable to identify a proxy, who will be able to express the patient’s wishes as reliably as possible.

Conclusion End-of-life decisions are complex and influenced by religious and cultural background. They must be guided by the four key ethical principles: beneficence, non-maleficence, patient autonomy, and distributive justice. ACPs are rarely relevant in the ICU. Every attempt must be made to facilitate an end-of-life with dignity and without suffering.