Surgeons, intensivists, and the covenant of care: Administrative models and values affecting care at the end of life

Abstract

End-of-life care varies according to the administrative model. When surgeons have primary responsibility for the patient, the most important goal is defeating death. When intensivists have sole patient responsibility, scarce resources are considered and quality of life is a significant variable. Discussions about improving the way end-of-life decisions are carried out in intensive care units rarely consider the administrative models and personal, professional, and national values affecting such decisions. To improve care at the end of life, we must critically examine these features.

Lessons Learned from a Palliative Care-Related Communication Intervention in an Adult Surgical Intensive Care Unit

“…Previous research suggests that, in surgical ICUs, palliative care-related communication is challenging for many cultural and pragmatic reasons [21][22][23][24]. Evidence from our own institution both suggest that surgeons, SICU nurses, and SICU intensivists and nurse practitioners have highly varying levels of satisfaction with communication regarding prognosis [25] and highlights SICU nurse-identified barriers to communication regarding prognosis [26].…”

Nurse-Perceived Barriers to Effective Communication Regarding Prognosis and Optimal End-of-Life Care for Surgical ICU Patients: A Qualitative Exploration (314-A)

“…22 Furthermore, optimal palliative care requires multiple, frequent, unhurried conversations about goals-ofcare, symptom-management, and prognosis; many surgeons, who already balance time-intensive operating room, clinic, and inpatient rounding schedules, do not have the time for these meetings. ICU physicians are hampered in that they frequently rotate on and off service; even assuming a semiopen or closed administrative model, 18 they frequently direct a patient's care for only a few days to a week -an often inadequate duration of time to build sufficient rapport with a patient and family. SICU nurses could direct palliative care discussions; however, previous studies note that patients want prognostic information from physicians 32 and even cite physicians to have an obligation to convey this information.…”

“…As compared to SICU physicians and surgeons, the nurse spends more time communicating with the patients' family regarding prognosis 26,27 and often acts as ''translator'' 18 or ''information giver'' 27 for patients and patient families. If there is conflict between physicians and families or between varying physician groups (such as between surgeons and ICU intensivists), the nurse may serve as a ''culture broker'' 28 attempting to mitigate conflicts.…”

“…[17][18][19][20][21] The time frame of surgical illness is often compressed, which requires patients, families, and clinicians to make difficult decisions in haste, without either clear information on patient prognosis or adequate emotional adjustment. 21 SICUs are more likely to use ''open'' or ''semiclosed'' administrative models 18 in which coordination of multiple care teams can be difficult.…”

“…[17][18][19][20][21] The time frame of surgical illness is often compressed, which requires patients, families, and clinicians to make difficult decisions in haste, without either clear information on patient prognosis or adequate emotional adjustment. 21 SICUs are more likely to use ''open'' or ''semiclosed'' administrative models 18 in which coordination of multiple care teams can be difficult. Surgical culture, with an overemphasis on clinician accountability for patient outcomes, 22 a ''rescue credo'' amongst surgeons, 23 and pride in technical, as opposed to psychosocial or spiritual aspects of patient care, 24 may also hamper incorporation of palliative care principles.…”