End-of-life issues in intensive care units: a national random survey of nurses' knowledge and beliefs

OBJECTIVE: To investigate the knowledge, beliefs, and ethical concerns of nurses caring for patients dying in intensive care units. METHODS: A survey was mailed to 3000 members of the American Association of Critical-Care Nurses. The survey contained various scenarios depicting end-of-life actions for patients: pain management, withholding or withdrawing life support, assisted suicide, and voluntary and nonvoluntary euthanasia. RESULTS: Most of the respondents (N = 906) correctly identified the distinctions among the end-of-life actions depicted in the scenarios. Almost all (99%-100%) agreed with the actions of pain management and withholding or withdrawing life support. A total of 83% disagreed with assisted suicide, 95% disagreed with voluntary euthanasia, and 89% to 98% disagreed with nonvoluntary euthanasia. Most (78%) thought that dying patients frequently (31%) or sometimes (47%) received inadequate pain medicine, and almost all agreed with the double-effect principle. Communication between nurses and physicians was generally effective, but unit-level conferences that focused on grief counseling and debriefing staff rarely (38%) or never (49%) occurred. Among the respondents, 37% had been asked to assist in hastening a patient's death. Although 59% reported that they seldom acted against their consciences in caring for dying patients, 34% indicated that they sometimes had acted against their conscience, and 6% had done so to a great extent. CONCLUSIONS: Intensive care unit nurses strongly support good pain management for dying patients and withholding or withdrawing life-sustaining therapies to allow unavoidable death. The vast majority oppose assisted suicide and euthanasia. Wider professional and public dialogue on end-of-life care in intensive care units is warranted.

Download Full-text

Physicians’ standpoints on end-of-life decisions at the neonatal intensive care units in Jordan

Journal of Child Health Care ◽

10.1177/1367493518814926 ◽

2019 ◽

Vol 23 (4) ◽

pp. 579-595 ◽

Cited By ~ 5

Author(s):

Nadin M Abdel Razeq

Keyword(s):

Decision Making ◽

Intensive Care ◽

End Of Life ◽

Intensive Care Units ◽

Neonatal Intensive Care ◽

Life Support ◽

Ethical Decision Making ◽

Healthcare Providers ◽

Ethics Committees ◽

Cross Sectional

The purpose of this cross-sectional descriptive study is to explore pediatricians’ and neonatologists’ attitudes and standpoints on end-of-life (EOL) decision-making in neonates. Seventy-five physicians, employed fulltime to care for newborns in 23 hospitals in Jordan, completed internationally accepted questionnaires. Most physicians (75%) were supportive of using life-sustaining interventions, irrespective of the severity of the newborns’ prognosis and the potential burden of the neonates’ disabilities on their families. The general attitude of the physicians (59–88%) was against making decisions that limit life support at EOL; even those infants with what are, in fact, untreatable and disabling medical conditions (56–88%). Most physicians (77%) indicated that ethics committees should be involved in EOL decision-making based on requests from parents, physicians, or both. The results of this study indicate strong pro-life attitudes among the physicians whose role is to take care of infants in Jordan. The results also emphasize the need for (1) the creation of clear EOL–focused regulations and guidelines, (2) the establishment of special ethical committees to inform and assist healthcare providers’ efforts during EOL care, and (3) raised awareness and competencies regarding EOL and ethical decision-making among physicians taking care of newborns in Jordan’s intensive care units.

Download Full-text

Intensive care nurses' experiences with end-of-life care

American Journal of Critical Care ◽

10.4037/ajcc2000.9.1.36 ◽

2000 ◽

Vol 9 (1) ◽

pp. 36-42 ◽

Cited By ~ 83

Author(s):

KT Kirchhoff ◽

V Spuhler ◽

L Walker ◽

A Hutton ◽

BV Cole ◽

...

Keyword(s):

Intensive Care ◽

Focus Group ◽

End Of Life ◽

Intensive Care Units ◽

End Of Life Care ◽

Care Staff ◽

Recent Experience ◽

Life Care ◽

Comfort Care ◽

Dying Patients

BACKGROUND: With much attention being focused on how patients die and whether or not they are provided appropriate care, the care of dying patients in intensive care units must be described and improved. OBJECTIVES: To describe end-of-life care in intensive care units as perceived by critical care nurses who have taken care of dying patients. METHODS: A semistructured interview guide was developed and revised after pretesting in a focus group of faculty clinicians with extensive, recent experience in intensive care. Four focus groups were held with randomly selected nurses from 4 intensive care units in 2 hospitals; participants had 2 years or more of experience and were working half-time or more. Tapes from each focus group were transcribed and reviewed by the investigators before the subsequent group met. Category labels were developed, and topics and themes were determined. RESULTS: "Good" end-of-life care in the intensive care unit was described as ensuring that the patient is as pain-free as possible and that the patient's comfort and dignity are maintained. Involvement of the patient's family is crucial. A clear, accurate prognosis and continuity of care also are important. Switching from curative care to comfort care is awkward. CONCLUSIONS: Disagreement among patients' family members or among caregivers, uncertainty about prognosis, and communication problems further complicate end-of-life care in intensive care units. Changes in the physical environment, education about end-of-life care, staff support, and better communication would improve care of dying patients and their families.

Download Full-text

The care of dying people in nursing homes and intensive care units: a qualitative mixed-methods study

Health Services and Delivery Research ◽

10.3310/hsdr04200 ◽

2016 ◽

Vol 4 (20) ◽

pp. 1-410 ◽

Cited By ~ 6

Author(s):

Elizabeth Perkins ◽

Maureen Gambles ◽

Rachel Houten ◽

Sheila Harper ◽

Alan Haycox ◽

...

Keyword(s):

Intensive Care ◽

Nursing Homes ◽

End Of Life ◽

Intensive Care Units ◽

End Of Life Care ◽

Unique Contribution ◽

Life Care ◽

Department Of Health ◽

Dying Patients ◽

The Impact

BackgroundIn England and Wales the two most likely places of death are hospitals (52%) and nursing homes (22%). The Department of Health published its National End of Life Care Strategy in July 2008 (Department of Health.End of Life Care Strategy: Promoting High Quality Care For All Adults at the End of Life. London: Department of Health; 2008) to improve the provision of care, recommending the use of the Liverpool Care Pathway for the Dying Patient (LCP).AimThe original aim was to assess the impact of the LCP on care in two settings: nursing homes and intensive care units (ICUs).DesignQualitative, matched case study.MethodsData were collected from 12 ICUs and 11 nursing homes in England: (1) documentary analysis of provider end-of-life care policy documents; (2) retrospective analysis of 10 deaths in each location using written case notes; (3) interviews with staff about end-of-life care; (4) observation of the care of dying patients; (5) analysis of the case notes pertaining to the observed patient’s death; (6) interview with a member of staff providing care during the observed period; (7) interview with a bereaved relative present during the observation; (8) economic analysis focused on the observed patients; and (9) strict inclusion and selection criteria for nursing homes and ICUs applied to match sites on LCP use/non-LCP use.ResultsIt was not possible to meet the stated aims of the study. Although 23 sites were recruited, observations were conducted in only 12 sites (eight using the LCP). A robust comparison on the basis of LCP use could not, therefore, take place. Although nurses in both settings reported that the LCP supported good care, the LCP was interpreted and used differently across sites, with the greatest variation in ICUs. Although not able to address the original research question, this study provides an unprecedented insight into care at the end of life in two different settings. The majority of nursing homes had implemented some kind of ‘pathway’ for dying patients and most homes participating in the observational stage were using the LCP. However, training in care of the dying was variable and specific issues were identified relating to general practitioner involvement, the use of anticipatory drugs and the assessment of consciousness and the swallowing reflex. In ICUs, end-of-life care was inextricably linked with the withdrawal of active treatment and controlling the pace of death. The data highlight how the decision to withdraw was made and, importantly, how relatives were involved in this process. The fact that most patients died soon after the withdrawal of interventions was reported to limit the appropriateness of the LCP in this setting.LimitationsAlthough the recruitment of matched sites was achieved, variable site participation resulted in a skewed sample. Issues with the sample size and a blurring of LCP use and non-use limit the extent to which the ambitious aims of the study were achieved.ConclusionsThis study makes a unique contribution to understanding the complexity of care at the end of life in two very different settings. More research is needed into the ways in which an organisational culture can be created within which the principles of good end-of-life care become translated into practice.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Download Full-text

Obstacles and Helpful Behaviors in Providing End-of-Life Care to Dying Patients in Intensive Care Units

Dimensions of Critical Care Nursing ◽

10.1097/dcc.0b013e3182808429 ◽

2013 ◽

Vol 32 (2) ◽

pp. 99-106 ◽

Cited By ~ 19

Author(s):

Marta Elena Losa Iglesias ◽

Cristina Pascual ◽

Ricardo Becerro de Bengoa Vallejo

Keyword(s):

Intensive Care ◽

End Of Life ◽

Intensive Care Units ◽

End Of Life Care ◽

Life Care ◽

Dying Patients

Download Full-text

Palliative Care/Physician-Assisted Dying: Alternative or Continuing Care?

Care Management Journals ◽

10.1891/cmaj.7.1.41 ◽

2006 ◽

Vol 7 (1) ◽

pp. 41-44 ◽

Cited By ~ 1

Author(s):

Marion Malakoff

Keyword(s):

Palliative Care ◽

End Of Life ◽

Advance Directives ◽

Assisted Suicide ◽

Life Support ◽

Care Physician ◽

Physician Assisted Suicide ◽

Dying Patients ◽

Physician Assisted Dying ◽

Wrongful Death

End-of-life care for dying patients has become an issue of importance to physicians as well as patients. The debate centers around whether the option of physician-assisted suicide cuts off, or diminishes the value of, palliative care. This ongoing attention makes the crafting of advance directives from patients detailing their end-of-life choices essential. Equally important is the appointment of a health care surrogate. The surrogate, when the patient is too ill to make decisions, should be empowered to make them in his stead. No American court has found a clinician liable for wrongful death for granting a request to refuse life support. An entirely separate issue is that of legalized physician-assisted suicide. As of this writing, only Oregon has made this legal (see Gonzales v. Oregon). It is likely that this issue will be pursued slowly through the state courts, making advance directives and surrogacy all the more crucial.

Download Full-text

Nurses’ autonomy in end-of-life situations in intensive care units

Nursing Ethics ◽

10.1177/0969733014547970 ◽

2014 ◽

Vol 22 (7) ◽

pp. 803-814 ◽

Cited By ~ 7

Author(s):

Maria Cristina Paganini ◽

Regina Szylit Bousso

Keyword(s):

Intensive Care Unit ◽

Decision Making ◽

Intensive Care ◽

End Of Life ◽

Intensive Care Units ◽

Life Support ◽

Qualitative Interviews ◽

Daily Basis ◽

Medical Council ◽

Institutional Ethics

Background: The intensive care unit environment focuses on interventions and support therapies that prolong life. The exercise by nurses of their autonomy impacts on perception of the role they assume in the multidisciplinary team and on their function in the intensive care unit context. There is much international research relating to nurses’ involvement in end-of-life situations; however, there is a paucity of research in this area in Brazil. In the Brazilian medical scenario, life support limitation generated a certain reluctance of a legal nature, which has now become unjustifiable with the publication of a resolution by the Federal Medical Council. In Brazil, the lack of medical commitments to end-of-life care is evident. Objective: To understand the process by which nurses exercise autonomy in making end-of-life decisions in intensive care units. Research design: Symbolic Interactionism and Corbin and Strauss theory methodology were used for this study. Participants and research context: Data were collected through single audio-recorded qualitative interviews with 14 critical care nurses. The comparative analysis of the data has permitted the understanding of the meaning of nurse’s experience in exercising autonomy relating to end-of-life decision-making. Ethical considerations: Institutional ethics approval was obtained for data collection. Participants gave informed consent. All data were anonymized. Findings: The results revealed that nurses experience the need to exercise autonomy in intensive care units on a daily basis. Their experience expressed by the process of increase opportunities to exercise autonomy is conditioned by the pressure of the intensive care unit environment, in which nurses can grow, feel empowered, and exercise their autonomy or else can continuously depend on the decisions made by other professionals. Conclusion: Nurses exercise their autonomy through care. They work to create new spaces at the same time that they acquire new knowledge and make decisions. Because of the complexity of the end-of-life situation, nurses must adopt a proactive attitude that inserts them into the decision-making process.

Download Full-text