Fruitful or futile: intensive care nurses' experiences and perceptions of medical futility

Muslim Jurisprudence on Withdrawing Treatment from Incurable Patients: A Directed Content Analysis of the Papers of the Islamic Fiqh Council of the Muslim World League

This study investigates the views of contemporary Muslim jurists about withdrawing treatment of the terminally ill. Its aim is threefold. Firstly, it analyses jurists' views concerning core themes within the process of withdrawing treatment. Secondly, it provides insight into fatwas about withdrawing treatment. Thirdly, it compares these views with current medical standards in Europe and the Atlantic world on withdrawing treatment. The data consisted of six papers by Muslim jurists presented at the conference of the Islamic Fiqh Council in 2015. We conducted a directed content analysis (DCA) through a predetermined framework and compiled an overview of all previous fatwas referred to in the papers, which are also analysed. The results show that the general consensus is that if health cannot be restored, treatment may be withdrawn at the request of the patient and/or his family or on the initiative of the doctor. The accompanying fatwa emphasizes the importance of life-prolonging treatment if this does not harm the patient. It becomes apparent in the fatwa that the doctor has the monopoly in decision-making, which is inconsistent with current medical standards in Europe. Managing disclosure in view of the importance of maintaining the hope of Muslim patients may challenge the doctor's obligation to share a diagnosis with them.

Futile life-sustaining treatment in the intensive care unit - nurse and physician experiences: meta-synthesis

BACKGROUND

Continuing futile life-sustaining treatment prolongs patients' suffering and family members' and medical staff's psychological distress. Additionally, continuing futile treatment is inefficient in healthcare resource distribution. Although the withdrawal of futile life-sustaining treatment is ideal, the prevalence is variable.

OBJECTIVE

To synthesise nurses' and physicians' experiences with continuing futile life-sustaining treatment in the intensive care unit.

DESIGN

This meta-synthesis was conducted following the thematic synthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses and Enhancing transparency in reporting the synthesis of qualitative research statement were used in reporting the synthesis of qualitative research statements.

METHODS AND DATA SOURCES

A systematic search was conducted following the inclusion and exclusion criteria in APA PsycINFO, CINAHL Plus, EMBASE, MEDLINE, PubMed and Web of Science in May 2023. Two reviewers independently screened and extracted the data. The extracted data were analysed using thematic analysis of qualitative research.

FINDINGS

A total of 16 studies were finally included, and 141 quotes were extracted and analysed. The main findings were categorised into four themes: (1) contextual and cultural diversity, (2) perceptions of futile treatment, (3) professional roles and responsibilities, and (4) emotional distress.

CONCLUSION

The study highlights the influence of culture, religion and family members, as well as perceptions of futile treatment among clinicians, on continuing futile life-sustaining treatment. Also, nurses' awareness of their roles and responsibilities in ensuring patients' comfort at end of life was revealed. This study informs future research to explore the experiences of futile life-sustaining treatment across various contexts.

A systematic review defining non-beneficial and inappropriate end-of-life treatment in patients with non-cancer diagnoses: theoretical development for multi-stakeholder intervention design in acute care settings

Background

Non-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life.

Aim

To define and understand determinants of  non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life.

Design

Systematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles.

Data sources

Cochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science.

Results

Sixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences.

Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to ‘Motivation to Address Conflict & Seek Agreement’ helped to lessen uncertainty around decision-making. Establishing agreement was reliant on ‘Valuing Clear Communication and Sharing of Information’. Reaching consensus was dependent on ‘Choices around Timing & Documenting of end-of-life Decisions’.

Conclusion

A framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool.

Trial registration

PROSPERO Protocol CRD42021214137.

Moral Distress and Perception of Futile Care among Nurses of Neonatal Care Units

Objectives:

Moral distress (MD), which is affected by several factors such as futile care provision and is considered the cause of adverse effects such as job dissatisfaction and decreased care quality, is a new concept attracting increasing academic interest. This study aims to assess the correlation between nurses’ perception of futile care and MD in neonatal care units.

Material and Methods:

This descriptive-correlational study was carried out among 115 nurses working in the neonatal intensive care units and neonatal special care units of two hospitals in West Azerbaijan Province during 2020. A demographic information form, the 21-item MD-Pediatric version scale, and the 17-item perception of futile care questionnaire were used to collect data and analysed using SPSS 16 software.

Results:

The results confirmed the direct correlation between MD and the perception of futile care. In addition, MD and the nurses’ perceptions of futile care were estimated to be moderate.

Conclusion:

The results of this study provide evidence to emphasise the need for further studies to investigate other causes of MD in neonatal units and find the solutions to make the work environment more ethical. Furthermore, the results provide the platform needed for hospital and university managers to make the necessary decisions and create the required changes in the educational curriculum of nursing students and provide the appropriate courses for neonatal unit nurses to improve their ability to cope with the MD caused by providing futile care.

The effect of professional education on medical and nursing students' attitudes toward death

This qualitative study aims to reveal the effect of professional education on medical and nursing students' attitudes toward death. The study was carried out with nursing and medical students (N = 197). Research data was collected through semi-structured interview questions and 23 focus group interviews. The data was assessed using thematic analysis method. The themes were evaluated within the context of perception of death, ethical dilemmas, and, death education. To achieve professional competency in attitudes toward death, it is imperative to form a common educational curriculum and practice that would help students develop a mutual language and value system about death.

Developing a Tool for Evaluation of Causes of Futile Care in Intensive Care Units

Background:

In Iran, futile care has become a challenge for intensive care nurses. The aim of the study was to develop a tool for assessing the reasons of futile care at intensive care units (ICUs).

Materials and Methods:

A sequential mixed method in three stages was applied. In the first stage, a phenomenological study was performed with van Manen's method by interviewing 25 nurses at ICUs of 11 hospitals in Qazvin. To extract the items of the tool in the second stage, the concept of futile care in ICUs and its reasons were defined. Ultimately, the psychometric properties of the questionnaire were evaluated with face validity, content validity (quantitative and qualitative), construct validity (exploratory factor analysis), internal consistency (Cronbach's alpha), and test–retest reliability.

Results:

The initial tool had 119 questions. After validation, 39 items remained in the final questionnaire. Five extracted factors were as follows: professional competence (14 items), organizational policy (9 items), socio-cultural factors (7 items), personal beliefs and values (4 items), and legal issues (5 items). Cronbach's alpha for the whole questionnaire was 0.91 (range: 0.71–0.96). The test–retest reliability was 0.87 (p < 0.001).

Conclusions:

Nursing managers and clinical nurses can use this tool to identify the causes of futile care and reduce it in their clinical settings. Policy makers can use this tool for improving the management of ICUs.

The role of the nurse at the end of the life of a critically ill patient

OBJECTIVE

Analyze the role of the nurse at the end of the life of a critically ill patient.

METHOD

Bibliographic review from a search of the health science databases such as PubMed, CINAHL, Cuiden, Scopus, Cochrane, as well as specialized platforms, general and thematic browsers. The limits were language (English or Spanish) and publication date (2005-2015).

RESULTS

180 articles met the inclusion criteria, and 16 of them were selected for analysis. The main results were grouped into three categories of analysis: direct patient care, family-focussed care and the nurse's role within the team.

CONCLUSIONS

the described roles place the nurse as a key element in humanising death in the ICU and so nurses can and must lead change, playing an active role in creating strategies that really promote the integration of a palliative care approach in ICU.

CUIDADOS PALIATIVOS AO IDOSO NA TERAPIA INTENSIVA: OLHAR DA EQUIPE DE ENFERMAGEM

RESUMO Objetivo: conhecer o significado de cuidados paliativos ao idoso para a equipe de enfermagem e identificar como ocorrem as interações da família com o idoso na unidade de terapia intensiva. Método: pesquisa descritiva, realizada unidade de terapia intensiva de hospital público em Fortaleza-Ceará-Brasil. Amostra composta por 58 profissionais da equipe de enfermagem. Fez-se a coleta de dados no segundo semestre de 2015 por meio de entrevista semiestruturada e gravada. Resultados: os resultados apontaram três categorias temáticas: cuidados paliativos, com destaque para alívioda dor e do sofrimento; interação familiar e pessoa idosa, sobressaindo comunicação como mais importante; e ambiente imprópriopara cuidados paliativos, com ênfase em orientação para o cuidado. Conclusão: conforme o estudo mostrou, a equipe tem conhecimento sobre cuidados paliativos e reconhece a família como elo entre profissional e idoso. Considera-se, ainda, que a terapia intensiva não é um ambiente apropriado para cuidados paliativos.

Clarification and Mitigation of Ethical Problems Surrounding Withdrawal of Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is temporary life-support technology that provides time to rest the cardiac and respiratory system of critically ill people with acute, reversible medical conditions. Health care providers face emotional and challenging situations, where death may result, when withdrawing ECMO. A deepening of understanding of the ethical issues involved can aid clinicians in handling such difficult situations, leading to a possible mitigation of the moral problems. Toward this end, the ethical issues raised in the consideration of ECMO withdrawal are analyzed with respect to the ethical principles and concepts of autonomy, nonmaleficence/beneficence, medical futility, moral distress, and justice. In particular, these issues are considered in relation to how they affect and can be addressed by staff nurses and advanced practice nurses in the intensive care unit. Advanced practice nurses in particular can represent the voice of nurses to promote a healthier workplace in situations of moral distress related to stopping ECMO life-support technology and in developing clear and consistent guidelines for ceasing ECMO treatment, all leading toward clarification and mitigation of the ethical problems surrounding the withdrawal of this critical technology.

Medically Timed Death as an Enactment of Good Death: An Ethnographic Study of Three European Intensive Care Units

The article is based on ethnographic observation and semistructured interviews with personnel in three European adult intensive care units. Intensive care is a domain of contemporary biomedicine centered on invasive and intense efforts to save lives in acute, critical conditions. It echoes our culture's values of longevity. Nevertheless, mortality rates are elevated. Many deaths follow from nontreatment decisions. Medicalized dying in technological medical settings are often presented as unnatural, impersonal, and undesirable ways of dying. How does this affect the way in which death is experienced by intensive care professionals? What might the enactment of dying in intensive care reveal about our cultural values of good and bad dying?

Perception of futile care and caring behaviors of nurses in intensive care units

OBJECTIVES:

Futile medical care is considered as the care or treatment that does not benefit the patient. Staff of intensive care units experience moral distress when they perceive the futility of care. Therefore, this study aimed to determine the relationship between perceptions of nurses regarding futile medical care and their caring behaviors toward patients in the final stages of life admitted to intensive care units.

METHOD:

This correlation, analytical study was conducted with 181 nursing staff of the intensive care units of health centers affiliated to Mazandaran University of Medical Sciences, Mazandaran, Iran. The data collection tool included a three-part questionnaire containing demographic characteristics form, perception of futile care questionnaire, and caring behaviors inventory. To analyze the data, statistical tests and central indices of tendency and dispersion were investigated using SPSS, version 19. Pearson's correlation coefficient, partial correlation, t-test, and analysis of variance tests were performed to assess the relationship between the variables.

ETHICAL CONSIDERATIONS:

The study was reviewed by the ethics committee of the Mazandaran University of Medical Sciences. Informed consent was obtained from participants.

RESULTS:

Our findings illustrated that the majority of nurses (65.7%) had a moderate perception of futile care, and most of them (98.9%) had desirable caring behaviors in taking care of patients in the final stages of life. The nurses believed that psychosocial aspects of care were of utmost importance. There was a significant negative relationship between perception of futile care and caring behavior.

CONCLUSION:

Given the moderate perception of nurses concerning futile care, and its negative impact on caring behaviors toward patients, implementing suitable interventions for minimizing the frequency of futile care and its resulting tension seems to be mandatory. It is imperative to train nurses on adjustment mechanisms and raise their awareness as to situations resulting in futile care.

Reasons behind providing futile medical treatments in Iran

Background:

Despite their negative consequences, evidence shows that futile medical treatments are still being provided, particularly to terminally ill patients. Uncovering the reasons behind providing such treatments in different religious and sociocultural contexts can create a better understanding of medical futility and help manage it effectively.

Research objectives:

This study was undertaken to explore Iranian nurses’ and physicians’ perceptions of the reasons behind providing futile medical treatments.

Research design:

This was a qualitative exploratory study. Study data were gathered through conducting in-depth semi-structured personal interviews and analyzed using the conventional content analysis method.

Participants and research context:

Twenty-one nurses and nine medical specialists were recruited purposively from four teaching hospitals affiliated to Tehran University of Medical Sciences.

Ethical considerations:

This study was approved by the Nursing and Midwifery Research Center and the Research Ethics Committee of Tehran University of Medical Sciences. All participants gave informed consent for the research and that their anonymity was preserved.

Findings:

The main theme of the study was “having an obligation to provide medical treatments despite knowing their futility.” This theme consisted of three main categories including patients’ and family members’ request for continuing life-sustaining treatments, healthcare professionals’ personal motives, and organizational atmosphere and structure.

Discussion and conclusion:

Different personal and organizational factors contribute to providing futile medical treatments. Promoting the structure and the function of hospital ethics committees, establishing and developing home care facilities, increasing the number of palliative care centers and hospices, and educating healthcare professionals, patients, and family members about the services and the benefits of such centers can facilitate making wise decisions about continuing or discontinuing treatments which have been labeled as futile.

Nurses' Perceptions of Futile Care: A Qualitative Study

Health care professionals believe that futile care must not be provided; however, there is no clear agreement over the definition and the manifestations of futile care. The aim of this study was to explore Iranian nurses' perceptions of futile care. In this qualitative exploratory study, the conventional content analysis approach was used for collecting and analyzing the study data. Three main themes were extracted from the data: nonfutility of care: care tantamount with outcome; sense of burnout; and subjectivity and relativity of medical futility concept.

Facing death in the intensive care unit. A phenomenological study of nurses' experiences

BACKGROUND

Nurses may experience considerable emotional burden due to patient death, in part as they are generally the professionals who have the most contact with patients.

OBJECTIVE

To describe the lived experience of Spanish nurses working in intensive care units regarding how they face the death of their patients.

METHODS

A qualitative phenomenological study was performed. A purposeful sample was used. The data collection strategies used included in-depth unstructured and semi-structured interviews, field notes and personal documents. Afterwards, data were analyzed using the Giorgi proposal.

RESULTS

22 nurses participated, with a mean age of 40.8 years and a mean work experience of 13.8 years. Three themes were identified: 1) dealing with expectations of recovery, 2) accepting the age of death, and 3) experiencing emotional attachment.

CONCLUSIONS

Nurses in intensive care units report a great emotional burden derived from patients death, Support programs for nurses should be organised within these units.

NURSES' PERCEPTIONS OF FUTILE MEDICAL CARE

The increasing progress in medical and health sciences has enhanced patient survival over the years. However, increased longevity without quality of life in terminally ill patients has been a challenging issue for care providers, especially nurses, since they are required to determine the futility or effectiveness of treatments. Futile care refers to the provision of medical care with futile therapeutic outcomes for the patient. Interest in this phenomenon has grown rapidly over the years. In this study, we aimed to review and identify nurses’ perceptions of futile care, based on available scientific resources. In total, 135 articles were retrieved through searching scientific databases (with no time restrictions), using relevant English and Farsi keywords. Finally, 16 articles, which were aligned with the study objectives, were selected and evaluated in this study. Overlapping studies were excluded or integrated, based on the research team’s opinion. According to the literature, futile care cannot be easily defined in medical sciences, and ethical dilemmas surrounding this phenomenon are very complex. Considering the key role of nurses in patient care and end-of-life decision-making and their great influence on the attitudes of patients and their families, support and counseling services on medical futility and the surrounding ethical issues are necessary for these members of healthcare teams.

[Nurses' perception, experience and knowledge of palliative care in intensive care units]

BACKGROUND

Adequate provision of palliative care by nursing in intensive care units is essential to facilitate a "good death" to critically ill patients.

OBJECTIVE

To determine the perceptions, experiences and knowledge of intensive care nurses in caring for terminal patients.

METHODOLOGY

A literature review was conducted on the bases of Pubmed, Cinahl and PsicINFO data using as search terms: cuidados paliativos, UCI, percepciones, experiencias, conocimientos y enfermería and their alternatives in English (palliative care, ICU, perceptions, experiences, knowledge and nursing), and combined with AND and OR Boolean. Also, 3 journals in intensive care were reviewed.

RESULTS

Twenty seven articles for review were selected, most of them qualitative studies (n=16). After analysis of the literature it has been identified that even though nurses perceive the need to respect the dignity of the patient, to provide care aimed to comfort and to encourage the inclusion of the family in patient care, there is a lack of knowledge of the end of life care in intensive care units' nurses.

CONCLUSION

This review reveals that to achieve quality care at the end of life, is necessary to encourage the training of nurses in palliative care and foster their emotional support, to conduct an effective multidisciplinary work and the inclusion of nurses in decision making.

Nurses' experiences of futile care at intensive care units: a phenomenological study

The concept and meaning of futile care depends on the existing culture, values, religion, beliefs, medical achievements and emotional status of a country. We aimed to define the concept of futile care in the viewpoints of nurses working in intensive care units (ICUs). In this phenomenological study, the experiences of 25 nurses were explored in 11 teaching hospitals affiliated to Social Security Organization in Ghazvin province in the northwest of Iran. Personal interviews and observations were used for data collection. All interviews were recorded as well as transcribed and codes, subthemes and themes were extracted using Van Manen's analysis method. Initially, 191 codes were extracted. During data analysis and comparison, the codes were reduced to 178. Ultimately, 9 sub-themes and four themes emerged: uselessness, waste of resources, torment, and aspects of futility.Nurses defined futile care as "useless, ineffective care giving with wastage of resources and torment of both patients and nurses having nursing and medical aspects" As nurses play a key role in managing futile care, being aware of their experiences in this regard could be the initial operational step for providing useful care as well as educational programs in ICUs. Moreover, the results of this study could help nursing managers adopt supportive approaches to reduce the amount of futile care which could in turn resolve some of the complications nurses face at these wards such as burnout, ethical conflicts, and leave.

Factors influencing the provision of end-of-life care in critical care settings: development and testing of a survey instrument

AIM

To develop and psychometrically test a survey instrument to identify the factors influencing the provision of end-of-life care by critical care nurses.

BACKGROUND

Following a decision to withdraw life-sustaining treatment, critical care nurses remain with the patient and their family providing end-of-life care. Identification of factors influencing the provision of this care can give evidence to inform practice development and support nurses.

DESIGN

A cross-sectional survey of critical care nurses.

METHOD

An online survey was developed, reviewed by an expert panel and pilot tested to obtain preliminary evidence of its reliability and validity. In May 2011, a convenience sample of critical care nurses (n = 392, response rate 25%) completed the survey. The analytical approach to data obtained from the 58 items measured on a Likert scale included exploratory factor analysis and descriptive statistics.

RESULTS

Exploratory factor analysis identified eight factors influencing the provision of end-of-life care: emotional support for nurses, palliative values, patient and family preferences, resources, organizational support, care planning, knowledge and preparedness. Internal consistency of each latent construct was deemed satisfactory. The results of descriptive statistics revealed a strong commitment to the inclusion of families in end-of-life care and the value of this care in the critical care setting.

CONCLUSION

This paper reports preliminary evidence of the psychometric properties of a new survey instrument. The findings may inform practice development opportunities to support critical care nurses in the provision of end-of-life care and improve the care that patients and their families receive.

Commitment to care: a qualitative study of intensive care nurses' perspectives of end-of-life care in an Islamic context

BACKGROUND

Currently, end-of-life care is a significant issue and a topic of debate in intensive care settings but understanding of nurses' perspectives about this within an Islamic context is surprisingly lacking.

AIM

The purpose of this study was to explore intensive care nurses' perspectives of the end-of-life care in South-east of Iran.

METHODS

A descriptive qualitative research approach was used to engage 12 intensive care nurses from three intensive care units of teaching hospitals affiliated to Kerman University of Medical Science in a semi-structured interview. Interview transcripts were analysed using an inductive coding approach.

RESULTS

Four major categories emerged from analysis of the interviews: commitment to care, awareness of dying patients, caring relationships, and dealing with barriers and ethical issues. The first category was emphasized and appeared dominant in all interviews.

LIMITATION

Because of specific socio-cultural and environmental factors, the findings of this study may not be applicable in other contexts, but enhance our knowledge about the topic in an Islamic context.

CONCLUSIONS

This study emphasizes the importance of looking at the end-of-life care for critical terminally ill patients within the context of spiritual milieu associated with commitment to a compassionate care until the last moment of their life. Intensive nurses, faced with various barriers and ethical issues, instead were focused on physical and spiritual care and believed that it should fulfil their role in the challenging process.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

These findings indicate that there is a need for policies that help increase the quality of life of dying patients. It is imperative that nursing managers and policy makers in Iran consider these findings to improve end-of-life care in intensive setting. More training programmes, further education and research on the topic, should be implemented.

Narratives of aggressive care: Knowledge, time, and responsibility

BACKGROUND

While witnessing and providing aggressive care have been identified as predominant sources of moral distress, little is known about what nurses "know" to be the "right thing to do" in these situations.

RESEARCH OBJECTIVES

The purpose of this study was to explore what nurses' moral knowledge is in situations of perceived overly aggressive medical care.

RESEARCH DESIGN

A critical narrative approach was used.

PARTICIPANTS

A total of 15 graduate nursing students from various practice areas participated.

FINDINGS

Four narrative types were identified, including "Wait and see: medical uncertainty," "Deflected responsibilities to respond to dying, death, or futility," "Divergent understandings, responsibilities, and temporalities," and "Privileged medical understandings and responsibilities."

DISCUSSION

The knowledge of differentially situated persons is acknowledged in dissimilar ways, the time required to determine that enough has been done is perceived differently, and how moral responsibilities are understood also varies.

CONCLUSIONS

A better understanding of how social roles influence how time, knowledge, and responsibility are related to the provision of aggressive care is needed.

A comparative survey on potentially futile treatments between Japanese nurses and laypeople

In the issue of futile treatments, patients and healthcare professionals tend to disagree. We conducted an Internet questionnaire survey and explored the Japanese nurses' attitude toward this topic, comparing with that of laypeople. In total, 522 nurses and 1134 laypeople completed the questionnaire. Nurse respondents were significantly less in favor of providing potentially futile treatments in hypothetical vignettes and stressed quality of life of the patient for judging the futility of a certain treatment. Of them, 85.4% reported having experienced providing such treatments. Reasons for providing them included factors related to not only patients but also healthcare teams. Our results indicate that attitudes among Japanese nurses toward the issue of futile treatments are different from patients and that their actual practice is influenced by several situational factors.

Challenges in end-of-life decisions in the intensive care unit: an ethical perspective

When making end-of-life decisions in intensive care units (ICUs), different staff groups have different roles in the decision-making process and may not always assess the situation in the same way. The aim of this study was to examine the challenges Danish nurses, intensivists, and primary physicians experience with end-of-life decisions in ICUs and how these challenges affect the decision-making process. Interviews with nurses, intensivists, and primary physicians were conducted, and data is discussed from an ethical perspective. All three groups found that the main challenges were associated with interdisciplinary collaboration and future perspectives for the patient. Most of these challenges were connected with ethical issues. The challenges included different assessments of treatment potential, changes and postponements of withholding and withdrawing therapy orders, how and when to identify patients' wishes, and suffering caused by the treatment. To improve end-of-life decision-making in the ICU, these challenges need to be addressed by interdisciplinary teams.

Medical futility in the care of non-competent terminally ill patient: nursing perspectives and responsibilities

BACKGROUND

Debate continues on the use of medical technology to prolong life independent of the quality of the outcomes. As a consequence, acute care nurses often find themselves in situations where they are asked to carry out physician's orders, in the context of a patient's deteriorating condition, which may be at odds with professional and personal ethical standards. This can cause nurses to become distressed when struggling with the ethical dilemmas involved with medical futility.

PURPOSE

This paper is a perspective on nursing considerations of our Code of Ethics and the concept of medical futility in acute nursing care. The utility of the Code is examined through a clinical vignette.

METHOD

A database search using the keywords medical futility and acute care limited to 2008 to 2012 and a secondary hand search of these references identified thirty journal publications. The Code of Ethics was examined via a clinical scenario pertinent to an acute environment.

FINDINGS

This paper examines the ethical principles that underpin nursing and illustrates how the code of ethics may serve as sign posts when faced with caring for a terminally ill patient that is inappropriately managed.

CONCLUSION

Understanding how individual nurses may address ethical dilemmas when faced with medical futility can better enable the nurse to fulfil their role as patient advocate, health promoter and alleviator of suffering. Ongoing education and communication to decrease any ambiguity or anguish associated with a patient's impending death optimises apt outcomes.

End-of-life practices in Danish ICUs: development and validation of a questionnaire

Background

Practices for withholding or withdrawing therapy vary according to professional, cultural and religious differences. No Danish-validated questionnaire examining withholding and withdrawing practices exists, thus the aim of this study was to develop and validate a questionnaire for surveying the views of intensive care nurses, intensivists, and primary physicians regarding collaboration and other aspects of withholding and withdrawing therapy in the ICU.

Methods

A questionnaire was developed on the basis of literature, focus group interviews with intensive care nurses and intensivists, and individual interviews with primary physicians. The questionnaire was validated in the following 3 phases: a qualitative test with 17 participants; a quantitative pilot test with 60 participants; and a survey with 776 participants. The validation process included tests for face and content validity (by interviewing participants in the qualitative part of the pilot study), reliability (by assessing the distribution of responses within the individual response categories), agreement (by conducting a test-retest, evaluated by paired analyses), known groups’ validity (as a surrogate test for responsiveness, by comparing two ICUs with a known difference in end-of-life practices), floor and ceiling effect, and missing data.

Results

Face and content validity were assessed as good by the participants in the qualitative pilot test; all considered the questions relevant and none of the participants found areas lacking. Almost all response categories were used by the participants, thus demonstrating the questionnaires ability to distinguish between different respondents, agreement was fair (the average test-retest agreement for the Likert scale responses was 0.54 (weighted kappa; range, 0.25-0.73), and known groups’ validity was proved by finding significant differences in level of satisfaction with interdisciplinary collaboration and in experiences of withdrawal decisions being unnecessarily postponed. Floor and ceiling effect was in accordance with other questionnaires, and missing data was limited to a range of 0-7% for all questions.

Conclusions

The validation showed good and fair areas of validity of the questionnaire. The questionnaire is considered a useful tool to assess the perceptions of collaboration and other aspects of withholding and withdrawing therapy practices in Danish ICUs amongst nurses, intensivists, and primary physicians.

Nursing Roles and Strategies in End-of-Life Decision Making in Acute Care: A Systematic Review of the Literature

The objective of this paper is to analyze the literature concerning nurses' roles and strategies in EOL decision making in acute care environments, synthesize the findings, and identify implications for future research. We conducted searches in CINAHL and PubMed, using a broad range of terms. The 44 articles retained for review had quantitative and qualitative designs and represented ten countries. These articles were entered into a matrix to facilitate examining patterns, themes, and relationships across studies. Three nursing roles emerged from the synthesis of the literature: information broker, supporter, and advocate, each with a set of strategies nurses use to enact the roles. Empirical evidence linking these nursing roles and strategies to patients and family members outcomes is lacking. Understanding how these strategies and activities are effective in helping patients and families make EOL decisions is an area for future research.

Withholding or withdrawing therapy in intensive care units: an analysis of collaboration among healthcare professionals

PURPOSE

The purpose of the study was to determine the views of intensive care nurses, intensivists, and primary physicians regarding collaboration and other aspects of withholding and withdrawing therapy in the intensive care unit (ICU).

METHODS

A questionnaire survey was conducted in seven hospitals in the Region of Southern Denmark, including six regional and four university ICUs. Four hundred ninety-five nurses, 135 intensivists, and 146 primary physicians participated in the study. The primary physicians came from two regional hospitals.

RESULTS

The unified response rate was 84%. "Futile therapy" and "Patient's wish" were for all participants the main reasons for considering withholding or withdrawing therapy. Of primary physicians 63% found their general experience of collaboration very or extremely satisfactory compared to 36% of intensivists and 27% of nurses. Forty-three percent of nurses, 29% of intensivists, and 2% of primary physicians found that decisions regarding withdrawal of therapy were often, very often, or always unnecessarily postponed. Intensivists with ICU as their main workplace were more satisfied with the collaboration and more rarely found that end-of-life decisions were changed or postponed compared to intensivists who did not have ICU as their main workplace.

CONCLUSION

Nurses, intensivists and primary physicians differ in their perception of collaboration and other aspects of withholding and withdrawing therapy practises at the ICU. Multi-disciplinary patient conferences, nurse involvement in the decision-making process, and guidelines for withholding and withdrawing therapy are recommended.

Registered nurses and moral distress

Nurses spend more time with patients at the end of life than any other member of the health care team, giving them early insight into futility-of-care issues for a particular patient. Providing futile care to dying patients is a well-known source of moral distress for nurses. Traditional ethical models are not always effective in dealing with these issues. The purpose of this article was to describe moral distress that is often experienced by nurses providing care to patients at the end of life and to propose the use of a model in dealing with associated ethical dilemmas in an effort to decrease the incidence of moral distress.

Staff empowerment in intensive care: nurses' and physicians' lived experiences

AIM

The purpose of the study was to describe empowerment from the perspective of intensive care staff. What makes intensive care staff experience inner strength and power?

BACKGROUND

Intensive care staff are repeatedly exposed to traumatic situations and demanding events, which could result in stress and burnout symptoms. A higher level of psychological empowerment at the workplace is associated with increased work satisfaction and mental health, fewer burnout symptoms and a decreased number of sick leave days.

METHOD

Open-ended interviews were conducted with 12 intensive care unit (ICU) staff (four registered nurses, four enrolled nurses and four physicians) in southern Sweden. Data were analysed using a phenomenological method.

FINDINGS

Intensive care staff were found to be empowered both by internal processes such as feelings of doing good, increased self-esteem/self-confidence and increased knowledge and skills, and by external processes such as nourishing meetings, well functioning teamwork and a good atmosphere.

CONCLUSION

Findings show that not only personal knowledge and skills, but also a supporting atmosphere and a good teamwork, has to be focused and encouraged by supervisors in order to increase staff's experiences of empowerment. Staff also need a chance to feel that they do something good for patients, next of kin and other staff members.

Culture and Organizational Climate: Nurses’ Insights Into Their Relationship With Physicians

Within any organization (e.g. a hospital or clinic) the perception of the way things operate may vary dramatically as a function of one’s location in the organizational hierarchy as well as one’s professional discipline. Interorganizational variability depends on organizational coherence, safety, and stability. In this four-nation (Canada, Ireland, Australia, and Korea) qualitative study of 42 nurses, we explored their perception of how ethical decisions are made, the nurses’ hospital role, and the extent to which their voices were heard. These nurses suggested that their voices were silenced (often voluntarily) or were not expressed in terms of ethical decision making. Finally, they perceived that their approach to ethical decision making differed from physicians.

Enacting death in the intensive care unit: medical technology and the multiple ontologies of death

This article explores various ways health personnel enact death in connection with mechanical ventilation treatment withdrawal in the intensive care unit (ICU) at Trondheim University Hospital. The main focus is on sedated terminal patients who undergo mechanical ventilator treatment withdrawal and relatives’ presence at this time. Mol’s (2002) praxiographic orientation of the actor-network approach is followed while exploring this medical practice. Utilizing this interdisciplinary science and technology studies approach this article describes what Timmermans and Berg (2003) have called ‘ technology-in-practice’. Thus the main focus of the analysis is on medical interventions, and enactments of death within medical practice. The article argues against a ‘social essentialist’ approach to medical technology, which views technology as a passive force empowered by social relations. It explores how various enactments of death are intrinsically linked with and shaped by the use of medical technology within clinical practice. A praxiographic inquiry into how death is enacted carefully takes notice of how medical practice and techniques make death audible, tangible, visible, knowable and real. Mol’s praxiographic approach also enables a description of how the multiple enactments of death connect within end-of-life care through various forms of coordination. This article is based on interviews with 28 nurses and two physicians in a Norwegian intensive care unit.

Life support decision making in critical care: Identifying and appraising the qualitative research evidence

OBJECTIVE

The objective of this study is to identify and appraise qualitative research evidence on the experience of making life-support decisions in critical care.

DATA SOURCES

In six databases and supplementary sources, we sought original research published from January 1990 through June 2008 reporting qualitative empirical studies of the experience of life-support decision making in critical care settings.

STUDY SELECTION

Fifty-three journal articles and monographs were included. Of these, 25 reported prospective studies and 28 reported retrospective studies.

DATA EXTRACTION

We abstracted methodologic characteristics relevant to the basic critical appraisal of qualitative research (prospective data collection, ethics approval, purposive sampling, iterative data collection and analysis, and any method to corroborate findings).

DATA SYNTHESIS

Qualitative research traditions represented include grounded theory (n = 15, 28%), ethnography or naturalistic methods (n = 15, 28%), phenomenology (n = 9, 17%), and other or unspecified approaches (n = 14, 26%). All 53 documents describe the research setting; 97% indicate purposive sampling of participants. Studies vary in their capture of multidisciplinary clinician and family perspectives. Thirty-one (58%) report research ethics board review. Only 49% report iterative data collection and analysis, and eight documents (15%) describe an analytically driven stopping point for data collection. Thirty-two documents (60%) indicated a method for corroborating findings.

CONCLUSIONS

Qualitative evidence often appears outside of clinical journals, with most research from the United States. Prospective, observation-based studies follow life-support decision making directly. These involve a variety of participants and yield important insights into interactions, communication, and dynamics. Retrospective, interview-based studies lack this direct engagement, but focus on the recollections of fewer types of participants (particularly patients and physicians), and typically address specific issues (communication and stress). Both designs can provide useful reflections for improving care. Given the diversity of qualitative research in critical care, room for improvement exists regarding both the quality and transparency of reported methodology.

Perceptions of "futile care" among caregivers in intensive care units

BACKGROUND

Many caregivers in intensive care units (ICUs) feel that they sometimes provide inappropriate or excessive care, but little is known about their definition of "futile care" or how they attempt to limit its impact. We sought to explore how ICU staff define medically futile care, why they provide it and what strategies might promote a more effective use of ICU resources.

METHODS

Using semi-structured interviews, we surveyed 14 physician directors, 16 nurse managers and 14 respiratory therapists from 16 ICUs across Ontario. We analyzed the transcripts using a modified grounded-theory approach.

RESULTS

From the interviews, we generated a working definition of medically futile care to mean the use of considerable resources without a reasonable hope that the patient would recover to a state of relative independence or be interactive with his or her environment. Respondents felt that futile care was provided because of family demands, a lack of timely or skilled communication, or a lack of consensus among the treating team. Respondents said they were able to resolve cases of futile care most effectively by improving communication and by allowing time for families to accept the reality of the situation. Respondents felt that further efforts to limit futile care should focus on educating the public and health care professionals about the role of the ICU and about alternatives such as palliative care; mandating early and skilled discussion of resuscitation status; establishing guidelines for admission to the ICU; and providing legal and ethical support for physicians who encounter difficulties. There was a broad consistency in responses among all disciplines.

INTERPRETATION

ICU physicians, nurses and respiratory therapists have similar and well-formed opinions about how to define and resolve medically futile care and where to focus future efforts to limit the impact of futile care in the ICU.