Towards a "good" death: end-of-life narratives constructed in an intensive care unit

Managing clinical uncertainty: An ethnographic study of the impact of critical care outreach on end-of-life transitions in ward-based critically ill patients with a life-limiting illness

Rapid response teams, such as critical care outreach teams, have prominent roles in managing end-of-life transitions in critical illness, often questioning appropriateness of treatment escalation. Clinical uncertainty presents clinicians with dilemmas in how and when to escalate or de-escalate treatment.

AIMS AND OBJECTIVES

To explore how critical care outreach team decision-making processes affect the management of transition points for critically ill, ward-based patients with a life-limiting illness.

METHODS

An ethnographic study across two hospitals observed transition points and decisions to de-escalate treatment, through the lens of critical care outreach. In-depth interviews were carried out to elucidate rationales for practices witnessed in observations. Detailed field notes were taken and placed in a descriptive account. Ethnographic data were analysed, categorised and organised into themes using thematic analysis.

FINDINGS

Data were collected over 74 weeks, encompassing 32 observation periods with 20 staff, totalling more than 150 hr. Ten formal staff interviews and 20 informal staff interviews were undertaken. Three main themes emerged: early decision-making and the role of critical care outreach; communicating end-of-life transitions; end-of-life care and the input of critical care outreach. Findings suggest there is a negotiation to achieve smooth transitions for individual patients, between critical care outreach, and parent or ward medical teams. This process of negotiation is subject to many factors that either hinder or facilitate timely transitions.

CONCLUSIONS

Critical care outreach teams have an important role in shared decision-making. Associated emotional costs relate to conflict with parent medical teams, and working as lone practitioners. The cultural contexts in which teams work have a significant effect on their interactions and agency.

RELEVANCE TO PRACTICE

There needs to be a cultural shift towards early and open discussion of treatment goals and limitations of medical treatment, particularly when facing serious illness. With training and competencies, outreach nurses are well placed to facilitate these discussions.

Living, dying, after death: Achieving a "good" death in the time of AIDS orphan care

AIDS has devastated communities across southern Africa, leaving many children orphaned. Grandmothers are considered ideal caregivers because of cultural expectations of intergenerational care, and because they have not been decimated by AIDS to the same extent as younger adults. However, these grandmothers, who currently carry the majority of the burden of care for AIDS orphans, are themselves aging and dying. I argue here that in Lesotho, the caregiving demanded of grandmothers late into their lives not only alters kin relations for the living but has increasingly made a "good" death unachievable for elderly caregivers.

Balancing professional tension and deciding upon the status of death: Making end-of-life decisions in intensive care units

This study investigated how intensivists make decisions regarding withholding and withdrawing treatment for patients at the end of their lives. This involved completing in-depth interviews from two sites of the South of England, United Kingdom by twelve intensivists. The data collected by these intensivists were analysed using thematic analysis. This resulted in the identification of three themes: intensivists' role, treatment effectiveness, and patients' best interest. Transcending these were two overarching themes relating to the balance between quantity and quality of life, and the intensivists' sense of responsibility versus burden. The results are considered in terms of making sense of death and the role of beliefs in the decision-making process.

Delirium as letting go: An ethnographic analysis of hospice care and family moral experience

BACKGROUND

Delirium is extremely common in dying patients and appears to be a major threat to the family's moral experience of a good death in end-of-life care.

AIM

To illustrate one of the ways in which hospice caregivers conceptualize end-of-life delirium and the significance of this conceptualization for the relationships that they form with patients' families in the hospice setting.

DESIGN

Ethnography.

SETTING/PARTICIPANTS

Ethnographic fieldwork was conducted at a nine-bed, freestanding residential hospice, located in a suburban community of Eastern Canada. Data collection methods included 15 months of participant observation, 28 semi-structured audio-recorded interviews with hospice caregivers, and document analysis.

RESULTS

Hospice caregivers draw on a culturally established framework of normal dying to help families come to terms with clinical end-of-life phenomena, including delirium. By offering explanations about delirium as a natural feature of the dying process, hospice caregivers strive to protect for families the integrity of the good death ideal.

CONCLUSION

Within hospice culture, there is usefulness to deemphasizing delirium as a pathological neuropsychiatric complication, in favor of acknowledging delirious changes as signs of normal dying. This has implications for how we understand the role of nurses and other caregivers with respect to delirium assessment and care, which to date has focused largely on practices of screening and management.

Personalizing death in the intensive care unit: the 3 Wishes Project: a mixed-methods study

BACKGROUND

Dying in the complex, efficiency-driven environment of the intensive care unit can be dehumanizing for the patient and have profound, long-lasting consequences for all persons attendant to that death.

OBJECTIVE

To bring peace to the final days of a patient's life and to ease the grieving process.

DESIGN

Mixed-methods study.

SETTING

21-bed medical-surgical intensive care unit.

PARTICIPANTS

Dying patients and their families and clinicians.

INTERVENTION

To honor each patient, a set of wishes was generated by patients, family members, or clinicians. The wishes were implemented before or after death by patients, families, clinicians (6 of whom were project team members), or the project team.

MEASUREMENTS

Quantitative data included demographic characteristics, processes of care, and scores on the Quality of End-of-Life Care-10 instrument. Semistructured interviews of family members and clinicians were transcribed verbatim, and qualitative description was used to analyze them.

RESULTS

Participants included 40 decedents, at least 1 family member per patient, and 3 clinicians per patient. The 159 wishes were implemented and classified into 5 categories: humanizing the environment, tributes, family reconnections, observances, and "paying it forward." Scores on the Quality of End-of-Life Care-10 instrument were high. The central theme from 160 interviews of 170 persons was how the 3 Wishes Project personalized the dying process. For patients, eliciting and customizing the wishes honored them by celebrating their lives and dignifying their deaths. For families, it created positive memories and individualized end-of-life care for their loved ones. For clinicians, it promoted interprofessional care and humanism in practice.

LIMITATION

Impaired consciousness limited understanding of patients' viewpoints.

CONCLUSION

The 3 Wishes Project facilitated personalization of the dying process through explicit integration of palliative and spiritual care into critical care practice.

PRIMARY FUNDING SOURCE

Hamilton Academy of Health Science Research Organization, Canadian Intensive Care Foundation.

[Limitation of therapeutic effort: Approach to a combined view]

Over the past few decades, we have been witnessing that increasing fewer people pass away at home and increasing more do so within the hospital. More specifically, 20% of deaths now occur in an intensive care unit (ICU). However, death in the ICU has become a highly technical process. This sometimes originates excesses because the resources used are not proportionate related to the purposes pursued (futility). It may create situations that do not respect the person's dignity throughout the death process. It is within this context that the situation of the clinical procedure called "limitation of the therapeutic effort" (LTE) is reviewed. This has become a true bridge between Intensive Care and Palliative Care. Its final goal is to guarantee a dignified and painless death for the terminally ill.

Honoring patient care preferences: surrogates speak

A growing body of evidence has pointed to the stressful experience surrounding surrogate decision-making on behalf of incapacitated patients. This study (N = 59) asked surrogates to speak about their experiences immediately after having made a life-sustaining treatment decision. Grounded theory analysis revealed four themes: (1) the emotional impact of the decision-making process on the surrogate; (2) the difficulty of watching a loved one's health deteriorate; (3) the importance of having a Living Will (LW) or other written/verbal instructions; and (4) the reliance on spirituality as a means of coping with the surrogate experience. Findings of this study suggest that engaging surrogates at the time of patient admission may be essential in order to clarify patient preferences and strengthen communication between surrogates and the interdisciplinary healthcare team.

Reinterpreting the hospital corridor: "wasted space" or essential for quality multidisciplinary clinical care?

The planning of New South Wales (NSW) and other Australian health facilities is guided by the Australasian Health Facility Guidelines (AHFG), which prescribe allowances for circulation (corridors and similar areas for movement between spaces) of between 10% and 40% of functional floor areas. A further allowance of up to 28% for Travel and Engineering is then assumed (University of NSW & Health Capital Asset Managers' Consortium, 2005). Therefore the "circulation" and "travel" space manifested as the corridors and similar movement spaces within health facilities is both extensive and expensive. Consequently, such space often becomes regarded as a necessary evil and, in the name of efficiency, is often minimized wherever possible. This paper revisits the view that corridor space allocations (circulation) must always be minimized to achieve design or functional efficiencies. Minimizing circulation or travel inevitably assumes that the realized space savings will then be reallocated to "more important" areas of the facility. Yet the corridors and other movement spaces also are very important to the functioning of multidisciplinary clinical teams and the quality of care delivery. Ultimately, inflexibly reducing the space allocated to such spaces may be regarded as a false economy.

Prognostic communication of critical care nurses and physicians at end of life

Many critical care nurses express reluctance to communicate prognostic information to patients and family members, especially prior to physician communication of this information. Yet, the findings from this study indicate that critical care nurses play a crucial, complementary role to physicians in prognostic communication. Nurses' contributions result in a broader picture of prognosis to patients and family members and facilitate end-of-life discussions.

Family members' informal roles in end-of-life decision making in adult intensive care units

BACKGROUND

To support the process of effective family decision making, it is important to recognize and understand informal roles that various family members may play in the end-of-life decision-making process.

OBJECTIVE

To describe some informal roles consistently enacted by family members involved in the process of end-of-life decision making in intensive care units.

METHODS

Ethnographic study. Data were collected via participant observation with field notes and semistructured interviews on 4 intensive care units in an academic health center in the mid-Atlantic United States from 2001 to 2004. The units studied were a medical, a surgical, a burn and trauma, and a cardiovascular intensive care unit.

PARTICIPANTS

Health care clinicians, patients, and family members.

RESULTS

Informal roles for family members consistently observed were primary caregiver, primary decision maker, family spokesperson, out-of-towner, patient's wishes expert, protector, vulnerable member, and health care expert. The identified informal roles were part of families' decision-making processes, and each role was part of a potentially complicated family dynamic for end-of-life decision making within the family system and between the family and health care domains.

CONCLUSIONS

These informal roles reflect the diverse responses to demands for family decision making in what is usually a novel and stressful situation. Identification and description of these informal roles of family members can help clinicians recognize and understand the functions of these roles in families' decision making at the end of life and guide development of strategies to support and facilitate increased effectiveness of family discussions and decision-making processes.

Measuring family satisfaction with care and quality of dying in the intensive care unit: does patient age matter?

RATIONALE

Few studies have examined the role of patient age on family experiences of end-of-life care.

OBJECTIVES

To assess measurement characteristics of two family-assessed questionnaires across three patient age groups.

METHODS

Four hundred and ninety-six patients who died in an intensive care unit (ICU) at a single hospital were identified and one family member per patient was sent two questionnaires: 1) Family Satisfaction in the ICU (FS-ICU); and 2) Quality of Dying and Death (QODD). Two hundred and seventy-five surveys were returned (55.4%). We analyzed three age groups: <35, 35-64, and ≥65 years. Differences were evaluated using χ(2) tests to evaluate ceiling, floor, and missing responses; Kruskal-Wallis tests to compare median scores on items and total scores; and linear regression controlling for patient sex, race, diagnosis, and family-member sex, race, education, and relationship to provide adjusted comparisons of total and subscale scores.

RESULTS

Measurement characteristics varied by age groups for both questionnaires. Missing values and floor endorsements were more common for the younger age groups for six items and one overall rating score. Ceiling endorsements were more common for the older group for 11 items. Fifteen items and four total scores were significantly higher in the older group.

CONCLUSIONS

The FS-ICU and QODD questionnaires performed differently across patient age groups. Assessments of family satisfaction and quality of dying and death were higher in the oldest group, particularly in the area of clinician-family communication. Studies of the dying experience of older adults may not generalize to patients of other ages, and study instruments should be validated among different age groups.

EvaIuating the "good death" concept from Iranian bereaved family members' perspective

Improving end-of-life care demands that first you define what constitutes a good death for different cultures. This study was conducted to evaluate a good death concept from the Iranian bereaved family members' perspective. A descriptive, cross-sectional study was designed using a Good Death Inventory (GDI) questionnaire to evaluate 150 bereaved family members. Data were analyzed by SPSS. Based on the results, the highest scores belonged to the domains "being respected as an individual," "natural death," "religious and spiritual comfort," and "control over the future." The domain perceived by family members as less important was "unawareness of death." Providing a good death requires professional caregivers to be sensitive and pay attention to the preferences of each unique person's perceptions. In order to implement holistic care, caregivers must be aware of patients' spiritual needs. Establishing a specific unit in a hospital and individually treating each patient as a valued family member could be the best way to improve the quality of end-of-life care that is missing in Iran.

Understanding the Person through Narrative

Mental health nurses need to know their clients at depth, and to comprehend their social contexts in order to provide holistic care. Knowing persons through their stories, narratives they tell, provides contextual detail and person-revealing characteristics that make them individuals. Narratives are an everyday means of communicating experience, and there is a place for storytelling in nearly all cultures. Thus narrative is a culturally congruent way to ascertain and understand experiences. This means the nurse should ask questions such as “How did that come about?” versus why questions. A narrative approach stands in contrast to a yes/no algorithmic process in conversing with clients. Eliciting stories illustrates the social context of events, and implicitly provides answers to questions of feeling and meaning. Here we include background on narrative, insights from narrative research, and clinical wisdom in explaining how narratively understanding the person can improve mental health nursing services. Implications for theory, practice, and research are discussed.

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.

"Living with dying": the evolution of family members' experience of mechanical ventilation

BACKGROUND

Communication with families about mechanical ventilation may be more effective once we gain a better understanding of what families experience and understand about this life support technology when their loved ones are admitted to the intensive care unit (ICU).

METHODS

We conducted in-depth interviews with family members of 27 critically ill patients who required mechanical ventilation for > or = 7 days and had an estimated ICU mortality of > or = 50%. Team members reviewed transcripts independently and used grounded theory analysis.

RESULTS

The central theme of family members' experience with mechanical ventilation was "living with dying." Initial reactions to the ventilator were of shock and surprise. Family members perceived no option except mechanical ventilation. Although the ventilator kept the patient alive, it also symbolized proximity to death. In time, families became accustomed to images of the ICU as ventilation became more familiar and routine. Their shock and horror were replaced by hope that the ventilator would allow the body to rest, heal, and recover. However, ongoing exposure to their loved one's critical illness and the new role as family spokesperson were traumatizing.

CONCLUSIONS

Family members' experiences and their understanding of mechanical ventilation change over time, influenced by their habituation to the ICU environment and its routines. They face uncertainty about death, but maintain hope. Understanding these experiences may engender more respectful, meaningful communication about life support with families.

Withdrawing Life-Sustaining Treatment: Ethical Considerations

Withdrawing life-supporting technology from patients who are irremediably ill is morally troubling for caregivers, patients, and families. Interventions that enable clinicians to delay death create situations in which the dignity and comfort of dying patients may be sacrificed to spare professionals and families from their elemental fear of death. Understanding of the limits of treatment, expertise in palliation of symptoms, skillful communication, and careful orchestration of controllable events can help to manage the withdrawal of life support appropriately.

A critical discourse analysis of provision of end-of-life care in key UK critical care documents

This article highlights certain practical and professional difficulties in providing end-of-life (EOL) care for patients in critical care units and explores discourses arising from guidelines for critical care services.

BACKGROUND

A significant number of patients die in critical care after decisions to withdraw or withhold treatment. Guidelines for provision of critical care suggest, wherever possible, moving patients out of critical care at the EOL. This may not necessarily be conducive to a 'good death' for patients or their loved ones. There is a moral responsibility for both nurses and doctors to ensure that decision-making around EOL issues is sensitively implemented, that decisions about care includes families, patients when able, nurses and doctors, and that good EOL care is provided.

METHODS

A critical discourse analysis (CDA) of four key UK critical care documents published since 1996.

FINDINGS AND RECOMMENDATIONS

The key documents give little clear guidance about how to provide EOL care in critical care. Discourses include the power dynamic in critical care between professions, families and patients, and how this impacts on provision of EOL care. Difficulties encountered include dilemmas at discharge and paternalism in decision-making. The technological environment can act as a barrier to good EOL care, and critical care nurses are at risk of assuming the dominant medical model of care. Nurses, however, are in a prime position to ensure that decision-making is an inclusive process, patient needs are paramount, the practical aspects of withdrawal lead to a smooth transition in goals of care and that comfort measures are implemented.

Supportive and palliative care needs identified by multiple sclerosis patients and their families

AIM

To identify the supportive needs of individuals with multiple sclerosis (MS) and their families. DESIGN, SAMPLE AND METHOD: In-depth interviews were carried out with people living with MS in the community, their family members and health professionals. The data were transcribed verbatim and recurring themes identified.

FINDINGS

The analysis of interviews revealed four themes: disbelief and devastation; losses and forced life choices; tracking down services and information; and sadness and relief.

CONCLUSION

Given the duration, range of symptoms and distress often associated with MS, the findings of this research raise the important question of the role of palliative services in supporting the person with MS and his/her family.

Withdrawing life-sustaining treatment: ethical considerations

In the community of caregivers, there is a general consensus that some heroic measures are not obligatory in certain circumstances that are defined by professional norms. For example, cardiopulmonary resuscitation in terminal cancer patients is not endorsed because of its violation of the dignity of the irremediably ill, and its unproductive cost to society. Moving back from this extreme, the availability and effectiveness of life-prolonging treatments, such as ventilators, dialysis, and implantable mechanical hearts, moves into a domain where the boundary limit of the obligation to preserve life is less clearly defined. When the continuing intervention of caregivers is essential to the prolongation of life, but the outcome and quality of residual life has deteriorated far below everyone's expectations when the treatment was initiated, caregivers are morally troubled as their treatments prolong the process of dying. Uncertainty or disputation about the prognosis raises the voltage of the fear and potential remorse that is a normal condition of care and support at the end of life. Unilateral decisions and overruling of objections should be avoided when possible, and reinforced by legal or ethical authorities when necessary. An ethics consultant, especially one skilled and experienced in management of end-of-life issues, can be a helpful negotiator and guide. The transition to palliative support should include the discontinuation of all unnecessary monitoring devices and tubes. Monitors should be turned off allowing families to direct their attention to the patient. Removing the monitor relieves family members from painful suspense and confusion. Removing the endotracheal tube sometimes allows conscious patients to talk to their loved ones, ending a silence forced on them by their treatment. If interventions are seen as masking the natural dying process, removing them should not be troubling. Their absence gives moral clarity to the elemental moments of closure at the end of life, no longer masked by futile contrivance. Withdrawal of life-sustaining treatment is a process that "merits the same meticulous preparation and expectation of quality that clinicians provide when they perform other procedures to initiate life support". Families and patients should never feel abandoned during this process and attention should be devoted to communicating that care is not being withdrawn. The family needs to be prepared for what the dying process may look like. Assure them that all energy is now being directed toward the comfort of the patient including sedation as required if signs of suffering are observed. Easing death, like easing birth, can be one of the most fulfilling contributions one can make to reduce the suffering and enrich the lives of patients and their families. Neglecting this part of the duty to provide appropriate care brings moral anguish to all participants in the peculiar circumstances that have come to surround death in the ICUs of developed countries. It is helpful to accept the inevitable reality that death is, in Shakespeare's words, a "necessary end" to all mortal life, and to recognize that defying death with technology can sometimes become an unnatural and degrading activity, however well motivated. The withdrawal of life-sustaining treatment, when conducted expertly, is a shared human experience that can be gratifying, although difficult for all concerned.

Nurse involvement in end-of-life decision making: the ETHICUS Study

OBJECTIVE

The purpose was to investigate physicians' perceptions of the role of European intensive care nurses in end-of-life decision making.

DESIGN

This study was part of a larger study sponsored by the Ethics Section of the European Society of Intensive Care Medicine, the ETHICUS Study. Physicians described whether they thought nurses were involved in such decisions, whether nurses initiated such a discussion and whether there was agreement between physicians and nurses. The items were analyzed and comparisons were made between different regions within Europe.

SETTING

The study took place in 37 intensive care units in 17 European countries.

PATIENTS AND PARTICIPANTS

Physician investigators reported data related to patients from 37 centers in 17 European countries.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Physicians perceived nurses as involved in 2,412 (78.3%) of the 3,086 end-of-life decisions (EOLD) made. Nurses were thought to initiate the discussion in 66 cases (2.1%), while ICU physicians were cited in 2,438 cases (79.3%), the primary physician in 328 cases (10.7%), the consulting physician in 105 cases (3.4%), the family in 119 cases (3.9%) and the patient in 19 cases (0.6%). In only 20 responses (0.6%) did physicians report disagreement between physicians and nurses related to EOLD. A significant association was found between the region and responses to the items related to nursing. Physicians in more northern regions reported more nurse involvement.

CONCLUSIONS

Physicians perceive nurses as involved to a large extent in EOLDs, but not as initiating the discussion. Once a decision is made, there is a sense of agreement. The level of perceived participation is different for different regions.

THE ANTHROPOLOGY OF THE BEGINNINGS AND ENDS OF LIFE

This essay reviews recent anthropological attention to the “beginnings” and “endings” of life. A large literature since the 1990s highlights the analytic trends and innovations that characterize anthropological attention to the cultural production of persons, the naturalization of life, and the emergence of new life forms. Part I of this essay outlines the coming-into-being, completion and attenuation of personhood and how life and death are attributed, contested, and enacted. Dominant themes include how connections are forged or severed between the living and the dead and the socio-politics of dead, dying, and decaying bodies. The culture of medicine is examined for its role in organizing and naming life and death. Part II is organized by the turn to biopolitical analyses stimulated by the work of Foucault. It encompasses the ways in which the biosciences and biotechnologies, along with state practices, govern forms of living and dying and new forms of life such as the stem cell, embryo, comatose, and brain dead, and it emphasizes the production of value. Much of this scholarship is informed by concepts of liminality (a period and state of being between social statuses) and subjectification (in which notions of self, citizenship, life and its management are linked to the production of knowledge and political forms of regulation).

Questioning Care at the End of Life

BACKGROUND

The goal of the larger study was to explore physicians' emotional responses to the death of their patients; this study analyzed a subset of physician transcripts to elucidate the construct of questioning care, which emerged from the larger study.

OBJECTIVE

To analyzes how physicians question care-expressing concern, unease, or uncertainty about treatment decisions and practices, errors, or adverse events-as they attend dying patients.

DESIGN

Retrospective interview study of physicians caring for randomly selected deaths on the medical service of a major academic teaching hospital, using qualitative and quantitative measures. SETTING, SUBJECTS: 188 attendings, residents, and interns on the internal medical services of two academic medical centers were part of the larger study. A subsample of 75 physician narratives was selected for qualitative data analysis for this study.

MEASUREMENTS

Qualitative measures included open-ended questions eliciting physicians' stories of the most recent and a most emotionally powerful patient death they have experienced. Grounded theory was used to analyze physician narratives. Quantitative instruments measured physician attitudes toward end-of-life care and responses to the most recent and most emotional patient death.

RESULTS

Physicians question care more frequently in most emotional deaths (42%) than in most recent deaths (34%). Physicians question communication with patients and families and within medical teams, medical judgment and technique, standards of practice, and high-risk treatments, often assigning responsibility for medical management they perceive as inappropriate, futile, overly aggressive, or mistakes in judgment and technique. Responsibility ranges from the distal (the culture of medicine) to the proximal (personal). Frustration, guilt, and anger are more frequently expressed in these narratives when care is questioned.

CONCLUSIONS

A typology of questioning care emerged from these physicians' narratives that parallels and reflects recent and classic research on medical error and the culture of medicine. Physicians' questions about care can contribute to designing training experiences for residents and to improving the quality of systems that affect patients' experiences at life's end and physicians' experiences in caring for dying patients.

Family perceptions of prognosis, silence, and the "suddenness" of death

Studies of end-of-life communication and care have emphasized physician-patient conversations, often to the exclusion of family members' discussions and interactions with providers, or with patients themselves. Relatively little is known therefore about families' experiences of end-of-life care in the hospital, or the concrete meanings and practices through which families conceive and define communication. Yet increasingly, family members are asked to serve as surrogates and thereby to participate in the facilitation of decisions for medical procedures and the withdrawal of treatments. It is thus worthwhile to consider their perceptions and involvement in hospitalization at the end of life. This paper offers a descriptive account of families' assessments of communication at life's end in the hospital--focusing in particular on their understandings of and conversations about prognosis and its implications. It reflects on the burdens of responsibility and regret posed to families by the ways communication is both conceived and evaded by different players in the hospital setting.

Stories, moral judgment, and medical care in an intensive care unit

A division of labor exists between nurses and doctors in a surgical intensive care unit. Nurses perform a culturally identified feminine expressive role, caring about patients as well as for them. Doctors perform a culturally identified masculine instrumental role, concerned with curing patients' bodies. The nurses are interested in the patients' stories; the doctors attempt to ignore the stories to concentrate on returning patients to function. Based on the patient's story, however, the nurses make severe judgments as to moral worth. Such judgments can impair medical care. Must doctors, then, disregard patients' stories? In other words, must they limit themselves to caring for patients' bodies, attempting to ignore the individuals, situated in a web of social relationships, who inhabit those bodies?

Narrative nuances on good and bad deaths: internists' tales from high-technology work places

Public and professional discourses in American society about what constitutes a "good death" have flourished in recent decades, as illustrated by the pivotal SUPPORT study and the growing palliative care movement. This paper examines a distinctive medical discourse from high-technology academic medical centers through an analysis of how physicians who are specialists in internal medicine tell stories about the deaths of patients in their care. 163 physicians from two major academic medical centers in the United States completed both qualitative open interviews and quantitative attitudinal measures on a recent death and on the most emotionally powerful death they experienced in the course of their careers. A subsample of 75 physicians is the primary source for the qualitative analysis, utilizing Atlas-ti."Good death" and "bad death" are common in popular discourse on death and dying. However, these terms are rarely used by physicians in this study when discussing specific patients and individual deaths. Rather, physicians' narratives are nuanced with professional judgments about what constitutes quality end-of-life care. Three major themes emerge from these narratives and frame the positive and negative characteristics of patient death. Time and Process: whether death was expected or unexpected, peaceful, chaotic or prolonged; Medical Care and Treatment Decisions: whether end-of-life care was rational and appropriate, facilitating a "peaceful" or "gentle" death, or futile and overly aggressive, fraught with irrational decisions or adverse events; Communication and Negotiation: whether communication with patients, family and medical teams was effective, leading to satisfying management of end-of-life care, or characterized by misunderstandings and conflict. When these physicians' narratives about patient deaths are compared with the classic sociological observations made by Glaser and Strauss in their study A Time for Dying (1968), historical continuities are evident as are striking differences associated with rapid innovation in medical technologies and a new language of medical futility. This project is part of a broader effort in American medicine to understand and improve end-of-life care.