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

Communication

Themes related to communication include the timing of EOL care discussions and difficult conversations. Participants expressed frustration and identified the negative implications of poorly timed discussions of EOL care.

Timing of EOL Care Discussions

Participants shared their experiences of the difficulties surrounding the timing of discussions of EOL care. Nurse and physician participants spoke about the need for discussions about a patient's EOL wishes earlier in their admission, before the patient's condition deteriorated. The participants recommended that these discussions should take place in the community, in the general care areas, or in the emergency department, before being admitted to the ICU, so that families can understand the wishes of their loved ones. "People need to understand what their own end-of-life wishes are before they end up as a MET [medical emergency team] call on the ward at midnight or being brought in by an ambulance from home at 2 in the morning. It's part of the broader conversation that we need, as a community, to have" (PG2, P3).

Poor timing of EOL care discussions was associated with patient and family distress, and discomfort for health care professionals directly involved with patient care. One physician stated that when EOL discussions are poorly timed, "you lose the trust of the family and that's a really distressing situation for staff, for the family, and patient, which really contributes to their grief" (PG2, P1). Nursing staff expressed their frustration associated with the poor timing of EOL care discussions, stating that these should be held earlier during the patient's admission. One nurse highlighted 1 of the reasons for poor timing of EOL care discussions: "The biggest barrier is the team recognition, incorporating the ICU multidisciplinary team and the external medical teams, that this process is actually underway, we acknowledge it's underway, and we're all heading in the right direction. You have different perspectives and, if not on the same page, then it's hard to institute a streamlined therapeutic approach towards end-of-life care" (NG2, P2).

Difficult Conversations

Difficult conversations and nurses' and physicians' inexperience in conducting difficult conversations were viewed as a major challenge by nurses and physicians. The nurses suggested strategies to improve their ability to conduct difficult conversations, including support and education from senior clinicians. Nurse participants also stressed that for them to improve their ability to conduct difficult conversations, "physicians and senior nurses should encourage nurses to attend family meetings" (NG3, P2). One nurse suggested that sometimes nursing staff were excluded from EOL care discussions with the family: "They [physicians] go and have the family meetings and a lot of nurses can't get to them due to staffing pressures, and they can't witness how some clinicians are excellent at conducting conversations about end of life" (NG2, P5). If nurses were able to attend family meetings more often, they would be able to observe the language that physicians use to enable difficult conversations. "More and more, I've been talking about 'we' with family members, so we're all on the same page, we're all working together to try and get their loved one better, but, unfortunately, their loved one has made the decision for us or the disease has made the decision for us and we wish we could have done more" (PG2 P4).

Physician participants also described their ability to conduct difficult conversations. Some physicians believed they had the competence and confidence to conduct conversations at EOL, whereas others were not so optimistic: "I think a lot of the time, our communication regarding difficult conversations is hopeless, not just for end-of-life care, but … everything" (PG1, P3).

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