Abstract
When making end-of-life decisions in intensive care units (ICUs), different staff groups have different roles in the decision-making process and may not always assess the situation in the same way. The aim of this study was to examine the challenges Danish nurses, intensivists, and primary physicians experience with end-of-life decisions in ICUs and how these challenges affect the decision-making process. Interviews with nurses, intensivists, and primary physicians were conducted, and data is discussed from an ethical perspective. All three groups found that the main challenges were associated with interdisciplinary collaboration and future perspectives for the patient. Most of these challenges were connected with ethical issues. The challenges included different assessments of treatment potential, changes and postponements of withholding and withdrawing therapy orders, how and when to identify patients’ wishes, and suffering caused by the treatment. To improve end-of-life decision-making in the ICU, these challenges need to be addressed by interdisciplinary teams.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Adhikari, N.K., R.A. Fowler, S. Bhagwanjee, and G.D. Rubenfeld. 2010. Critical care and the global burden of critical illness in adults. The Lancet 376(9749): 1339–1346.
Azoulay, E., J.F. Timsit, C.L. Sprung, et al. 2009. Prevalence and factors of intensive care unit conflicts: The conflicus study. American Journal of Respiratory and Critical Care Medicine 180(9): 853–860.
Bach, V., J. Ploeg, and M. Black. 2009. Nursing roles in end-of-life decision making in critical care settings. Western Journal of Nursing Research 31(4): 496–512.
Cassell, J., T.G. Buchman, S. Streat, and R.M. Stewart. 2003. Surgeons, intensivists, and the covenant of care: Administrative models and values affecting care at the end of life. Critical Care Medicine 31(5): 1551–1557.
Connors, A.F., N.V. Dawson, N.A. Desbiens, et al. 1995. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. The Journal of the American Medical Association 274(20): 1591–1598.
Curtis, J.R., D.J. Cook, R.J. Wall, et al. 2006. Intensive care unit quality improvement: A “how-to” guide for the interdisciplinary team. Critical Care Medicine 34(1): 211–218.
Curtis, J.R., and J.L. Vincent. 2010. Ethics and end-of-life care for adults in the intensive care unit. The Lancet 376(9749): 1347–1353.
Danish Ministry of Health. 2012. Instruction for preceding deselection of life-sustaining therapy, including attempted resuscitation and withdrawal of therapy [in Danish]. VEJ no. 33. https://www.retsinformation.dk/Forms/R0710.aspx?id=141135.
Ellingsen, L.L. 2002. Communication, collaboration, and teamwork among health care professionals. Communication Research Trends 21(3): 3–21.
Fagerlin, A., and C.E. Schneider. 2004. Enough: The failure of the living will. The Hastings Center Report 34(2): 30–42.
Ferrand, E., F. Lemaire, B. Regnier, et al. 2003. Discrepancies between perceptions by physicians and nursing staff of intensive care unit end-of-life decisions. American Journal of Respiratory and Critical Care Medicine 167(10): 1310–1315.
Graneheim, U.H., and B. Lundman. 2004. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24(2): 105–112.
Halvorsen, K., R. Førde, and P. Nortvedt. 2009. Value choices and considerations when limiting intensive care treatment: A qualitative study. Acta Anaesthesiologica Scandinavica 53(1): 10–17.
Heland, M. 2006. Fruitful or futile: Intensive care nurses’ experiences and perceptions of medical futility. Australian Critical Care 19(1): 25–31.
Jensen, H.I., J. Ammentorp, M. Erlandsen, and H. Ørding. 2011. Withholding or withdrawing therapy in intensive care units: An analysis of collaboration among healthcare professionals. Intensive Care Medecine 37(10): 1696–1705.
Kvale, S. 1996. InterViews: An introduction to qualitative research interviewing. Thousand Oaks: Sage Publications.
Puntillo, K.A., and J.L. McAdam. 2006. Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: Challenges and opportunities for moving forward. Critical Care Medicine 34(11 suppl): S332–S340.
Reynolds, S., A.B. Cooper, and M. McKneally. 2007. Withdrawing life-sustaining treatment: Ethical considerations. The Surgical Clinics of North America 87(4): 919–936.
Rushton, C.H., and J.A. Brooks-Brunn. 1997. Environments that support ethical practice. New Horizons 5(1): 20–29.
Schmidt, T.A., S.E. Hickman, and S.W. Tolle. 2004. Honoring treatment preferences near the end of life: The Oregon Physician Orders for Life-Sustaining Treatment (POLST) program. Advances in Experimental Medicine and Biology 550: 255–262.
Siegel, M.D. 2009. End-of-life decision making in the ICU. Clinics in Chest Medicine 30(1): 181–194.
Sprung, C.L., S.L. Cohen, P. Sjokvist, et al. 2003. End-of-life practices in European intensive care units: The ethicus study. The Journal of the American Medical Association 290(6): 790–797.
Stroud, R. 2002. The withdrawal of life support in adult intensive care: An evaluative review of the literature. Nursing in Critical Care 7(4): 176–184.
Studdert, D.M., M.M. Mello, J.P. Burns, et al. 2003. Conflict in the care of patients with prolonged stay in the ICU: Types, sources, and predictors. Intensive Care Medicine 29(9): 1489–1497.
Svantesson, M., P. Sjokvist, and H. Thorsen. 2003. End-of-life decisions in Swedish ICUs. How do physicians from the admitting department reason? Intensive & Critical Care Nursing 19(4): 241–251.
Wulff, H.R. 1995. The Samaritan duty. The ethical foundation for Danish Healthcare [in Danish]. Copenhagen: Munksgaard.
Acknowledgments
The authors thank all staff for taking part in the study.
Statement of Competing Interests
The authors have no competing interests.
Funding
The study was supported by The Region of Southern Denmark, Lillebaelt Hospital, Denmark, and the philanthropic foundation TrygFonden, Denmark. None of the funding bodies had any role in designing the study, collecting or analysing data, and writing and submitting the manuscript.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Jensen, H.I., Ammentorp, J., Johannessen, H. et al. Challenges in End-of-Life Decisions in the Intensive Care Unit: An Ethical Perspective. Bioethical Inquiry 10, 93–101 (2013). https://doi.org/10.1007/s11673-012-9416-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11673-012-9416-5