Recently across the developed world, there has been an increase in the occurrence of withdrawal of life-sustaining treatment (WLST) in ICUs (Burns, Sellers, Meyer, Lewis-Newby & Truog, 2014). There is a great deal of literature relating to WLST but to date, there is no data relating to the ethical perspectives of nurses and physicians when making decisions about WLST in ICU and the impact these decisions have on them. Where a patient possesses the mental capacity to make a decision, the preferences of the patient should prevail (Beauchamp & Childress, 2012). However, 95% of patients in ICUs are unable to participate in decision-making regarding life-sustaining treatments (Wright, Strong & Welters, 2011). In these circumstances a collaborative decision involving the patient’s significant others and the ICU team should prevail (Monteiro, 2014). Nurses have an active role in the implementation of such decisions and therefore it is argued that they should be involved in the decision-making process (McLeod, 2014).
Therefore the purpose of this study was to determine the factors that influence decision-making when considering withdrawal of life-sustaining treatment (WLST) in ICU; and the level of collaboration between nurses and physicians when making such decisions. To explore the process of WLST and how it affects nurses and physicians in view of their personal ethical perspectives.
Methods:
Using narrative inquiry, a purposive sample of six senior nurses and five intensivists, who have experience of caring for patients from whom life-sustaining treatment has been withdrawn in ICU, was recruited from a major tertiary hospital in metropolitan Western Australia.
Narrative inquiry is based firmly in the premise that, as human beings, we come to understand and give meaning to our lives through story (Creswell, 2013). Thus, narrative inquiry is the study of the activities involved in generating and analyzing stories of life experiences and reporting the results (De Fina & Georgakopoulou, 2012). Therefore, during narrative interviews, participants were asked to recount personal stories relevant to the issue of interest, while relevant probing questions were used when appropriate. Participants were asked to choose stories that highlighted what they considered to be exemplars of good practice, or situations that left them with a level of discomfort, or culminated in ethical tension.
Following the interviews, transcriptions were ‘re-storied’, which is an important process in narrative inquiry, involving reorganising and rewriting the story to place it within a chronological sequence (Creswell, 2013). Restorying commenced as each interview transcription was completed and the rewritten story was submitted to the participant for member checking to ensure the narrative produced, captured the essence of the discussion. The stories are treated as data and analysis allows themes to emerge that hold within and across stories. Analysis commenced after the first interview and was a continuous process, with content from each interview being used to inform and enhance the following interviews. To triangulate the data, the themes emerging from the narrative interviews were further explored and validated during a focus group discussion.
Results:
Eight major themes emerged from the narratives:
1). The Drivers.
This theme refers to the factors that drive the decision to withdraw life-sustaining treatment to be considered and/or made.
2. The Pushmi-pullu Effect.
This theme relates to how nursing and medical staff feel pushed into various actions and as a result may feel emotionally pulled in different directions.
3. The Beast of Burden.
This theme refers to the burden of the decision resting solely on the shoulders of the intensivist.
4. War and Peace.
This theme relates to professional discord and conflict arising as a result of differing perspectives, whilst the team remained cohesive and respectful of each other.
5. The Emotions.
This theme highlights moral distress and differing emotions arising as a result of a delayed decision and the prolongation of the dying process.
6. A Tree with many Branches.
This theme describes the visualisation of a flexible model of decision-making.
7. Letting Die.
This theme refers to the differing processes of withdrawing life-sustaining treatment.
8. Benefit and Harm. This theme relates to the differing ethical perspectives of nurses and physicians related to WLST.
Conclusion:
The study has determined that the ethical perspectives of nurses and physicians differ in relation to WLST in one ICU. It has provided a platform for further work to develop a model of decision-making relating to WLST in ICU, which could be transferable to other ICU environments locally, nationally or internationally. A link between a lack of collaboration in the decision-making process relating to WLST, moral distress and professional conflict has been determined. Public education is required to ensure families discuss their values with regard to end-of-life decision-making to reduce suffering in the dying patient, as it is considered that a family’s refusal to allow WLST can result in the prolongation of the dying process.