Decision-Making by Default: Experiences of Physicians and Nurses with Dying Patients in Intensive Care

Article excerpt

The purpose of this qualitative research study was to understand the experience of doctors and nurses while working with dying patients in the intensive care unit (ICU). Data was collected through individual taped and transcribed interviews with eight staff physicians, six house staff, and seven nurses, who were selected to reflect differences of age, sex, experience and ethnicity. All interviewees acknowledged that overtreatment of dying patients makes working in ICU difficult. House staff acknowledged feelings of failure at the death of their patients. Staff physicians acknowledged that it is easier to continue treating than to make a decision to stop, thus avoiding difficult conversations or ethical decisions. Physicians find end-of-life decision making and care significantly burdensome. When end-of-life decisions are not given adequate attention, the result is "decision making by default." All health care providers, including physicians, would benefit from a more collaborative approach, and greater support and education in dealing with death, dying and ethical decision-making.

Introduction

Modern medical treatments, coupled with society's denial of death, make it difficult to die in an urban teaching hospital. An increasing number of difficult ethical dilemmas and choices centre around the type and number of interventions to offer to critically ill patients. As a former nurse and practicing chaplain, I have been present at many deaths. Deaths that are accepted and relatively peaceful, especially in a palliative care setting, can be a positive and encouraging experience for those involved. Deaths that follow aggressive intervention, and pain, suffering, and that are resisted by patients, families and caregivers, can be negative and discouraging for those involved. The purpose of this study was to explore the impact on ICU physicians and nurses of caring for dying patients whom they perceive to be over or undertreated.(1) This knowledge was sought in an effort to make care for the dying more humane for all those involved.

While intensive care plays an important part in the management of patients who eventually will recover from their illnesses, the study focused on the experience of staff caring for patients who were unlikely to recover. The ICU is the setting that has the greatest ability to delay death by monitoring and intervening in all the major bodily systems, even though aggressive medical care of dying patients also happens elsewhere. This paper will touch upon some significant themes that emerged from this study and suggest what we might gain from the application of this knowledge.

Background

Solomon et al(2) surveyed 687 physicians and 759 nurses from five American hospitals. They reported that 7 in 10 house staff, 5 in 10 nurses, and between 3 and 4 of 10 attending physicians said that they acted against their consciences when providing care to the terminally ill. As well, four times as many health-care providers said they were concerned about overtreatment than said they were concerned about undertreatment. Seventy-eight percent of the house officers and 58% of staff physicians reported that sometimes they offered treatments that were "overly burdensome" to their patients. Furthermore, 80% of respondents reported that, in the care of the dying, the most common form of narcotic "abuse" is undertreatment of pain.

In a Canadian study, Cook et al gave doctors and nurses the same patient scenarios and asked them to rate the importance of 17 pre-determined factors, such as "likelihood of surviving current episode," "patient advance directives," or "pre-morbid cognitive function," in considering withdrawal of life supports. They found that, while ICU doctors and nurses consistently identify a number of patient factors as important, the respondents showed extreme variability in the level of care they chose for the same scenario. In part this variation can be explained by the personal values of individual health- care providers. …