Speaking about dying in the intensive care unit, and its implications for multidisciplinary end-of-life care

Abstract

This article addresses how professionals working in an intensive care unit in Australia speak about dying, with particular reference to the contradictions and complexities that characterize their work in this setting. The article reflects on the incommensurabilities in these clinicians' talk, and the consequences of this for how different professionals work together and care for extremely ill patients. Examples are drawn from talk recorded during ward rounds and focus groups. The article argues that intensive care units are settings where being reflexive about one's work and assumptions is especially difficult because it involves negotiating decisions and taking moral responsibility for decisions affecting very sick patients. These decisions and responsibilities put into sharp relief the 'wicked problems and tragic choices' of end-of-life existence and of intensive care in specific. This article shows some of the complex ways in which specific clinicians' discourse absorbs and manifests these tensions and responsibilities. The article concludes that these kinds of complexities are unlikely to be resolved with reference to formal knowledge or in-principle conviction, and that a new interactive basis needs to be found where clinicians can rehearse alternative ways of speaking with which to approach each other, the dying, and their families.

Beyond profession: nursing leadership in contemporary healthcare

“…Following in‐depth observational work and dynamic in situ interviewing, a number of intensive care themes were mapped out. These themes have since been written about extensively (Iedema et al. 2004, 2005, Sorensen & Iedema 2006, 2007, 2008).…”

The (dis)appearance of the dying patient in generalist hospital and care home nurses' talk about the patient

“…A study of talk by intensive care unit doctors and nurses recorded from ward rounds and focus group interviews is concerned with the way clinicians discursively manage tensions and responsibilities inherent in the highly charged care situation (Iedema et al. , 2004).…”

“…Two features of this talk are discursive repetition, e.g. reproduction numerous times of a dichotomy such as technical‐rational medicine and confronting the experience of personal/familial disaster (Iedema et al. , 2004, p. 87) and disjunction using contradictory terms that signal ‘elements that are divided .…”

“…A study of talk by intensive care unit doctors and nurses recorded from ward rounds and focus group interviews is concerned with the way clinicians discursively manage tensions and responsibilities inherent in the highly charged care situation (Iedema et al, 2004). The authors point out the limited exploration of how clinicians discursively construct self in relation to dying and death and what this means for communication and decision making concerning the dying.…”

Emergent modes of work and communities of practice

“…31 Crucially, accounting here serves not in the first instance the purpose of reporting up the chain, but of sense-making by, for and with those involved. 32 That said, we still need to specify conducts that realize these processes. It is here that we will draw on the terms participating, knowledging and boundary spanning.…”