Communication and Decision-Making About End-of-Life Care in the Intensive Care Unit

Laura Anne Brooks, RN, MN; Elizabeth Manias, RN, BPharm, MPharm, MNStud, PhD, DLF-ACN, MPSA, MSHPA; Patricia Nicholson, RN, PhD

Disclosures

Am J Crit Care. 2017;26(4):336-341. 

In This Article

Abstract and Introduction

Abstract

Background Clinicians in the intensive care unit commonly face decisions involving withholding or withdrawing life-sustaining therapy, which present many clinical and ethical challenges. Communication and shared decision-making are key aspects relating to the transition from active treatment to end-of-life care.

Objectives To explore the experiences and perspectives of nurses and physicians when initiating end-of-life care in the intensive care unit.

Methods The study was conducted in a 24-bed intensive care unit in Melbourne, Australia. An interpretative, qualitative inquiry was used, with focus groups as the data collection method. Intensive care nurses and physicians were recruited to participate in a discipline-specific focus group. Focus group discussions were audio-recorded, transcribed, and subjected to thematic data analysis.

Results Five focus groups were conducted; 17 nurses and 11 physicians participated. The key aspects discussed included communication and shared decision-making. Themes related to communication included the timing of end-of-life care discussions and conducting difficult conversations. Implementation and multidisciplinary acceptance of end-of-life care plans and collaborative decisions involving patients and families were themes related to shared decision-making.

Conclusions Effective communication and decision- making practices regarding initiating end-of-life care in the intensive care unit are important. Multidisciplinary implementation and acceptance of end-of-life care plans in the intensive care unit need improvement. Clear organizational processes that support the introduction of nurse and physician end-of-life care leaders are essential to optimize outcomes for patients, family members, and clinicians.

Introduction

With the dramatic increase in medical capacity, capability, and technology, one of the greatest challenges in the intensive care unit (ICU) is that prolonged life support is easily sustained.[1] The predicted risk of death in the ICU for adult patients is about 13.0% in Australia and 12.8% in New Zealand,[2] and approximately 22.0% of deaths in the United States occur after admission to the ICU.[3] Many patients require withdrawal of active treatment and initiation of end-of-life (EOL) care, with variations between ICUs acknowledged.[4,5]

Communication and shared decision-making are key aspects in the transition from active treatment to EOL care. Issues surrounding communication involve both clinicians' discomfort with discussing prognosis and inadequate skills and training,[6] which lead to clinicians' inexperience in conducting difficult conversations.[7–9] Promotion of shared decision-making,[9–11] family presence at EOL,[9,12] and working in a supportive environment with a collaborative multidisciplinary team11,[13] are all necessary for good EOL care. However, the literature highlights poor interdisciplinary collaboration and conflict between clinicians as major issues6–9 that reduce the quality of EOL care provided to patients, families, and care providers.1,10 It is important to learn more about local communication and decision-making practices at EOL to help provide localized strategies for improvement in initiating EOL care in the ICU.

The aim of this study was to explore the experiences and perspectives of nurses and physicians when initiating EOL care in the ICU.

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