Objective: Of the approximately 6.5 million deaths in the United States each year, 60% occur in hospitals and the chances of spending time in an ICU during the last six months of life range from 9-47%. The results of several recent research studies have increased awareness of the inadequacies of end-of-life care in the ICU where the transition from curative to palliative care is not evenly recognized or acknowledged. Prolonging the living/dying process with inappropriate measures has also been identified as a profoundly disturbing ethical issue for many nurses. The objective of this study was to explore what indicators expert critical care nurses describe and communicate about poor patient prognosis and what they do when their perceptions of the usefulness of continued aggressive medical interventions differed from family members and/or physicians.
Design: An combined qualitative design employing narrative and thematic analysis of interview data.
Population, Sample, Setting, Years: The sample consisted of twenty one critical care nurses nominated as experts by a clinical nurse specialist or nurse educator in their facility. The participants practiced in a variety of adult critical care units in one of three, teaching medical centers, three private institutions, or one community hospital in Southwest Texas. The data was collected over a nine month period from September, 2000 to May, 2001.
Conceptual/Sensitizing Framework: The sensitizng framework for the study was the construct of expertise as explicated in nursing and other disciplines, integrating cognitive, intrinsic, and moral components.
Methods: Interviews were conducted with twenty-one expert adult critical care nurses. Participant responses that had a temporal ordering of events were analyzed using narrative analytic methods. A thematic analysis was conducted on those responses that did not take a narrative form.
Findings: The participants were often the first to recognize poor patient prognosis and, in so doing, integrated knowledge from three areas: clinical, relational, and ethical. When the expert nurses' perceptions of the usefulness of aggressive treatments differed from family members, they attempted to present a realistic picture, determine the patients' wishes, and consult additional resources such as pastoral care. Distancing or tempering involvement with the family and patient was used as a protective strategy if the participants were unable to influence the course of treatment. When perceptions differed from physicians, the participants communicated their understanding of the patients' deteriorating status, failure to respond to interventions, and patient/ family wishes and concerns. In addition, they attempted to encourage empathy and consulted additional resources such as palliative care or the ethics committee.
Conclusions: The expert participants related narratives or provided responses that described situations of extreme patient vulnerability. Vulnerability is ethically significant as it refers to the fact that people can be injured, not only in terms of health, but in their ability to determine the ends of life. For many participants, their recognition of this vulnerability, conceived as ethical discernment or sensitivity, implied responsibility. The professional value of responsibility did not presume paternalism but rather mutuality and assisting patients to actualize their choices and enhance their dignity. Promoting or restoring patient dignity often involved speaking for the patient and preventing further technological intrusion which was seen as dehumanizing and ultimately, futile.
Implications: Contrary to the findings of several studies, many of the expert critical care nurses in this investigation actively participated in end-of-life decision making. The participants did not act because of previously learned ethical principles or rules, but because of their personal perception of good or ethical practice. The language of ethical principles, therefore, may not adequately inform or describe the lived moral experiences of nurses. Relational narratives, such as those described by the expert participants, may contribute to the development of an experiential, practice based account of nursing ethics. Practicing nurses and students could learn from the narratives of other nurses, perhaps enhancing ethical discourse and cohesion.
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