Objective: The study objective was to describe and explicate the construct "attending physician" in the context of studying end-of-life decision making in intensive care units (ICUs). The term attending physician commonly is used in ICUs to identify the physician with ultimate authority for the patient's treatment plan, including end-of-life decisions, writing treatment limitation orders, daily charting to document circumstances of these orders, and communicating with the family to initiate and implement end-of-life treatment. In trying to understand the roles and communication processes governing the management of end-of-life decision making, it became clear that identifying the attending physician responsible for such actions was not a simple matter for staff or families; and that attending physician is a complex construct. Design: Prospective ethnographic study. Population, Sample, Setting, Years: The population of interest was patients, families, and healthcare providers in ICUs making decisions about limiting life-sustaining treatments for critically ill patients. Participants were care providers, family members, and/or patients involved in making such decisions in the setting of two ICUs (medical and surgical) in a tertiary care center/university teaching hospital. The data were collected in 2000 and 2001. Concept or Variables Studied: Culture was the central construct, defined as shared knowledge and customary actions that express, mark, and maintain social systems. Culture is embedded in social relationships, social identities, and rules for action. Persons in social systems such as ICUs are linked through a variety of social relations. They fill roles, exercise rights and privileges, and are expected to discharge obligations and responsibilities in conformity with established values and norms. To assess previous work on the attending role in ICU culture, a search of the medical literature (Medline, 1966-2001) by text word (attending physician) and by subject terms (medical staff, hospital and physician's role) produced 20 relevant citations. All of these works took the term "attending" at face value, as a term needing no clarification. Methods: Participant observation and semi-structured interviews. Findings: There was a lack of clarity about assigning the role of attending physician in the observational and interview data from the two ICUs. On the medical ICU generally the intensivists were officially the attendings, but some patients had attendings from specialty services, such as neurology. In other cases, neurologists served as consultants. Although the patient's primary care provider, who is the attending in the community setting, was not usually the attending in the social system of the ICUs, in at least one instance in the medical ICU the primary care provider retained attending status. Moreover, in the complex system of the tertiary care center, attending status often resided with a group of physicians with rotating role responsibility. Thus, the intensivist assigned as the attending for an individual patient on one day might not be the attending the next because it was the weekend or the beginning of a new week or month, when another member of the group became the attending. Physicians were observed asking residents, "Am I the attending[today]?" In the surgical ICU an intensivist was the unit director and managed the day-to-day treatment decisions post-surgery. But the attendings of record were the surgeons, who were largely invisible on the unit. Complex and often informal understandings between the unit director and the surgical staff governed the assignment of treatment decisions, especially for those decisions involving limitation of treatment and transitions to end-of-life care. In summary, though the putative attending was posted in medical records and on wall charts, those names sometimes differed from each other and from verbal report. It was not simple to discover who the attending was, how information about who was the attending physician was conveyed to the person in that role and to others, or what being the attending signified in terms of responsibility. Implications for Practice and Knowledge Development: The complexity and difficulty of determining who the attending was on any given day had consequences for staff and families in identifying who was responsible for initiating end-of-life communication and decisions, the timeliness and clarity of communications among and between staff and family, and staff and family satisfaction with end-of-life treatment and communication. Further investigation of the definition, meaning, role, difficulty of identification, and consequences of ambiguity about attending status for staff, patients, and family members is needed in the complex social/care systems of different types of ICUs in order to enhance the quality of care of critically ill patients and their families and to expand knowledge related to this key position.
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