Structure and variation in end-of-life discussions in the Surgical Intensive Care Unit

Abstract

The research reported here is an exploratory discourse analysis of a corpus of six end-of-life discussions in a Surgical Intensive Care Unit (SICU), describing the structure and variations of the four phases of an end-of-life discussion in terms of the function of each of these phases: the Opening (Phase 1), Description of Current Status (Phase 2), Holistic Decision Making (Phase 3), and Logistics of Dying (Phase 4). Of particular interest is Phase 2, in which the presentation of medical information culminates in an inferential summary statement that functions to establish the patient's status as terminal. We argue that it is Phase 2 that is crucial in the functional progression of an end-of-life discussion toward a decision to move from therapeutic to palliative care, since it is in Phase 2 that physicians and families interactionally achieve a consensus that allows a decision to withdraw or withhold further treatment, including life support, which would be futile and only prolong the patient's suffering. We show how two of the end-of-life discussions in the corpus that did not establish the terminal status of the patient in Phase 2 did not move to decision making in Phase 3.

The Distinct Role of Palliative Care in the Surgical Intensive Care Unit

“…40 DNR consent may be reversed because of an unforeseeable event or iatrogenic concern as a result of the physician's sense of responsibility, potential litigation, and a belief that the advance directive did not apply in a particular circumstance. 41 Nonetheless, conversations considering withdrawal of life support 42 permit an open discussion recognizing that the patient has a grave and possibly terminal prognosis. This discussion should be followed by a balance of ordinary and medical language while explaining the situation and then an agreement on end-of-life care plans.…”

End-of-Life Care in an Acute Care Hospital: Linking Policy and Practice

“…Thus, shifting from cure to comfort care is a negotiated event that requires skilled handling (Bowman, 2000). Yet, the process of bringing family members into the decision-making arena can be a missed step if they are unprepared for their surrogate role and if family members' own needs for understanding and support are ignored (Barton, Aldridge, Trimble, & Vidovic, 2005).…”

Integrating patients' nonmedical status in end-of-life decision making: Structuring communication through 'conferencing'

“…End-of-life discussions can be anticipated, phased, structured, and therefore planned (Barton et al 2005). The experienced nurse speaking in Excerpt (9) describes the processes needed to achieve 'a nice death'.…”