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

Discussion

This study shows that there is a clear gap in communication practices of clinicians who conduct discussions with patients and patients' families regarding plans for EOL care. Despite extensive focus in practice on initiating and delivering EOL care, conflict between health care teams often contributed to poor timing of EOL care discussions, affecting timely commencement of EOL care plans. Nurses and physicians both recognized that EOL discussions are occurring too late in a patient's hospital admission and that further work is required to improve the communication skills of clinicians and collaboration between health care teams to promote early EOL conversations, a finding identified in other studies.[14,15] Losing the trust of the family and experiencing low levels of family satisfaction were emphasized by participants as implications of poor timing of EOL care discussions.

As identified in this study, the structure and formality of an EOL care plan contribute to a more streamlined approach to EOL care; however, multidisciplinary acceptance of the EOL care plan has been identified as an obstacle. Lack of multidisciplinary acceptance may be due to several reasons, including cultural differences4 and disagreements between ICU physicians and nurses and external medical teams.[16,17] Implications associated with lack of multidisciplinary acceptance of EOL care plans include prolongation of dying related to missed opportunities to provide optimal EOL care[18] and moral and emotional distress among patients, families, and health care providers.[8,19,20]

The importance of shared decision-making and providing family-centered care in the ICU at EOL has been emphasized in the literature.[1,14,21,22] In Australia, shared decision-making is recommended when developing EOL care plans; however, the views and wishes of the patient and family are relevant but not determinative in decision-making based on the patient's best interests.[15,23] This situation poses many ethical challenges for health care staff, particularly when there are complex family dynamics and unrealistic family expectations.[1,24] Nursing and medical EOL care leaders are required to encourage clinicians to communicate with each other in the multidisciplinary team, and with family members, to promote a shared decision-making approach to EOL care. Clear organizational processes with a collaborative decision-making framework must be in place to facilitate these leadership roles in establishing early EOL care plans where appropriate.

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