Physician Approaches to Conflict with Families Surrounding End-of-Life Decision-making in the Intensive Care Unit. A Qualitative Study

Mehter, Hashim M; McCannon, Jessica; Clark, Jack A.; Wiener, Renda Soylemez

doi:10.1513/annalsats.201702-105oc

Cited by 27 publications

(34 citation statements)

References 33 publications

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“…The RToP suggests that in making decisions as to whether to withdraw futile treatment, physicians face catalysts in the form of doubts surrounding their roles in the provision of EoL care, the alleviation of suffering and their patient’s right to die [ 36 , 37 ]. The moral, existential, personal and professional conflict between ICs in their Innate Ring is also made manifest in their Individual Ring as they face anxiety and doubts over their knowledge, skills and ability to provide effective and empathic care for these dying patients and their families as they meet their clinical obligations [ 38 , 39 ].…”

Section: Discussionmentioning

confidence: 99%

The impact of caring for dying patients in intensive care units on a physician’s personhood: a systematic scoping review

Kuek

Ngiam

Kamal

et al. 2020

Philos Ethics Humanit Med

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Background Supporting physicians in Intensive Care Units (ICU)s as they face dying patients at unprecedented levels due to the COVID-19 pandemic is critical. Amidst a dearth of such data and guided by evidence that nurses in ICUs experience personal, professional and existential issues in similar conditions, a systematic scoping review (SSR) is proposed to evaluate prevailing accounts of physicians facing dying patients in ICUs through the lens of Personhood. Such data would enhance understanding and guide the provision of better support for ICU physicians. Methods An SSR adopts the Systematic Evidenced Based Approach (SEBA) to map prevailing accounts of caring for dying patients in ICUs. To enhance the transparency and reproducibility of this process, concurrent and independent use of tabulated summaries, thematic analysis and directed content analysis (Split Approach) is adopted. Results Eight thousand three hundred fifty-eight abstracts were reviewed from four databases, 474 full-text articles were evaluated, 58 articles were included, and the Split Approach revealed six categories/themes centered around the Innate, Individual, Relational and Societal Rings of Personhood, conflicts in providing end of life care and coping mechanisms employed. Conclusion This SSR suggests that caring for dying patients in ICU impacts how physicians view their personhood. To resolve conflicts within individual concepts of personhood, physicians use prioritization, reframing and rely on accessible, personalized support from colleagues to steer coping strategies. An adapted form of the Ring Theory of Personhood is proposed to direct timely personalized, appropriate and holistic support.

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Section: Discussionmentioning

confidence: 99%

The impact of caring for dying patients in intensive care units on a physician’s personhood: a systematic scoping review

Kuek

Ngiam

Kamal

et al. 2020

Philos Ethics Humanit Med

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show abstract

“…As the vast majority of ICU patients survive their stay, 30 and many studies are focused on the end-of-life patient category, our patient and family member sampling focused on ICU survivors. [31][32][33][34] Patient and public involvement Former patients and family members were involved in the preparatory phase of this study. Patient organisation board members and the audience members of a patient organisation symposium were asked for input into the topic of SDM in the ICU, which informed the development of the two semistructured topic guides used in this study (see: online supplemental material 2).…”

Section: Participant Samplingmentioning

confidence: 99%

Shared decision-making in the ICU from the perspective of physicians, nurses and patients: a qualitative interview study

et al. 2021

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ObjectiveTo identify views, experiences and needs for shared decision-making (SDM) in the intensive care unit (ICU) according to ICU physicians, ICU nurses and former ICU patients and their close family members.DesignQualitative study.SettingTwo Dutch tertiary centres.Participants19 interviews were held with 29 participants: seven with ICU physicians from two tertiary centres, five with ICU nurses from one tertiary centre and nine with former ICU patients, of whom seven brought one or two of their close family members who had been involved in the ICU stay.ResultsThree themes, encompassing a total of 16 categories, were identified pertaining to struggles of ICU physicians, needs of former ICU patients and their family members and the preferred role of ICU nurses. The main struggles ICU physicians encountered with SDM include uncertainty about long-term health outcomes, time constraints, feeling pressure because of having final responsibility and a fear of losing control. Former patients and family members mainly expressed aspects they missed, such as not feeling included in ICU treatment decisions and a lack of information about long-term outcomes and recovery. ICU nurses reported mainly opportunities to strengthen their role in incorporating non-medical information in the ICU decision-making process and as liaison between physicians and patients and family.ConclusionsInterviewed stakeholders reported struggles, needs and an elucidation of their current and preferred role in the SDM process in the ICU. This study signals an essential need for more long-term outcome information, a more informal inclusion of patients and their family members in decision-making processes and a more substantial role for ICU nurses to integrate patients’ values and needs in the decision-making process.

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“…Discussions about end-of-life decisions happen at times of unexpected crisis, involve new and complex information, and require time-sensitive decisions. [9][10][11] HCPOAs and surrogate decision-makers typically have varying degrees of experience and comfort with decision-making. 12 Additionally, HCPOAs and surrogate decision-makers frequently have a poor understanding of patient wishes because, in many cases, there is limited discussion between patients and HCPOAs/surrogate decision-makers about goals-of-care prior to acute illness.…”

Section: Introductionmentioning

confidence: 99%

Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting

Rath

Tucker

Lewis

2021

Am J Hosp Palliat Care

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Background: There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient’s wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions. Methods: Case report and discussion of the associated ethical issues. Results: We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team. Conclusion: It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.

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Physician Approaches to Conflict with Families Surrounding End-of-Life Decision-making in the Intensive Care Unit. A Qualitative Study

Cited by 27 publications

References 33 publications

The impact of caring for dying patients in intensive care units on a physician’s personhood: a systematic scoping review

The impact of caring for dying patients in intensive care units on a physician’s personhood: a systematic scoping review

Shared decision-making in the ICU from the perspective of physicians, nurses and patients: a qualitative interview study

Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting

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