Critical care nurses' experiences of ethical challenges in end-of-life care

BACKGROUND

In Swedish intensive care units, nine percent of patients do not survive despite receiving advanced life-sustaining treatments. As these patients transition to end-of-life care, ethical considerations may become paramount.

AIM

To explore the ethical challenges that critical care nurses encounter when caring for patients at the end of life in an intensive care context.

RESEARCH DESIGN

The study used a qualitative approach with an interpretive descriptive design.

RESEARCH CONTEXT AND PARTICIPANTS

Twenty critical care nurses from eight intensive care units in an urban region in Sweden were interviewed, predominately women with a median age of fifty-one years.

ETHICAL CONSIDERATIONS

This study was approved by The Swedish Ethics Review Authority.

FINDINGS

Critical care nurses described encountering ethical challenges when life-sustaining treatments persisted to patients with minimal survival prospects and when administering pain-relieving medications that could inadvertently hasten patients' deaths. Challenges also arose when patients expressed a desire to withdraw life-sustaining treatments despite the possibility of recovery, or when family members wanted to shield patients from information about a poor prognosis; these wishes occasionally conflicted with healthcare guidelines. The critical care nurses also encountered ethical challenges when caring for potential organ donors, highlighting the balance between organ preservation and maintaining patient dignity.

CONCLUSION

Critical care nurses encountered ethical challenges when caring for patients at the end of life. They described issues ranging from life-sustaining treatments and administration of pain-relief, to patient preferences and organ donation considerations. Addressing these ethical challenges is essential for delivering compassionate person-centered care, and supporting family members during end-of-life care in an intensive care context.

Critical care: A concept analysis

Objective

The terms critical care and the Intensive Care Unit (ICU) are often used interchangeably to describe a place of care. Defining critical care becomes challenging because of the colloquial use of the term. Using concept analysis allows for the development of definition and meaning. The aim of this concept analysis is to distinguish the use of the term critical care to develop an operational definition which describes what constitutes critical care.

Method

Walker and Avant's eight-step approach to concept analysis guided this study. Five databases (CINAHL, Scopus, PubMed, ProQuest Dissertation Abstracts and Medline in EBSCO) were searched for studies related to critical care. The search included both qualitative and quantitative studies written in English and published between 1990 and 2022.

Results

Of the 439 papers retrieved, 47 met the inclusion criteria. The defining attributes of critical care included 1) a maladaptive response to illness/injury, 2) admission modelling criteria, 3) advanced medical technologies, and 4) specialised health professionals. Antecedents were associated with illness/injury that progressed to a level of criticality with a significant decline in both physical and psychological functioning. Consequences were identified as either death or survival with/without experiencing post-ICU syndrome.

Conclusion

Describing critical care is often challenging because of the highly technical nature of the environment. This conceptual understanding and operational definition will inform future research as to the scope of critical care and allow for the design of robust evaluative instruments to better understand the nature of care in the intensive care environment.

The role of technology in critical care nursing

AIM

This paper is a report of a study to identify the meaning for critical care nurses of technology related to weaning from mechanical ventilation and to explore how that technology was used in practice.

BACKGROUND

The literature concerned with the development of critical care (intensive care and high dependency units) focuses mainly on innovative medical technology. Although this use of technology in critical care is portrayed as new, it actually represents a transfer of technology from operating theatres.

METHOD

An ethnographic study was conducted and data were collected on one critical care unit in a large teaching hospital over a 6-month period in 2004. The methods included participant observation, interviews and the collection of field notes.

FINDINGS

The overall theme 'The nursing-technology relation' was identified. This comprised three sub-themes: definition of technology, technology transferred and technology transformed. Novice nurses took a task-focussed approach to weaning, treating it as a 'medical' technology transferred to them from doctors. Expert nurses used technology differently and saw its potential to become a 'nursing technology'.

CONCLUSION

Nurses need to examine how they can adapt and to 'reconfigure' technology so that it can be transformed into a nursing technology. Those technologies that do not fit with nursing may have no place there. Rather than simply extending and expanding their roles through technology transfer, nurses should transform those technologies that preserve the essence of nursing and can contribute to a positive outcome for patients.

The development of critical care in England

The paper offers a view of the development of critical care from the position of nursing. The nursing contribution is not fully acknowledged in the historical and professional literature. This paper offers an alternative history of the development of intensive care (ICU), which takes account of the nursing profession's contribution, rather than the commonly held view that ICU developed predominately as a result of new and innovative technology. The technology was not new but rather it was transferred, usually from the operating theatre, and applied to new conditions. There were many contributing factors that shaped the development of intensive care. One was the grouping together of sick patients so that they could be cared for by skilled nurses who 'watched over' them, by providing detailed observation. This paper outlines the development of intensive care in England from 1952 to the new millennium. It begins with an analysis of the changing definitions reflected in policy and professional documents before moving on to examine the factors that influenced its development and concludes with a discussion of the nursing contribution and future direction.