Intensive care nurses' and physicians' experiences with demands for treatment: some implications for clinical practice

Abstract

Objective: This study was conducted to develop an empiric description of intensive care unit (ICU) physicians' and nurses' (participants) experiences providing life-sustaining treatments at the insistence of family members, treatments that they believed should have been withheld or withdrawn. From this description, steps to minimize or prevent their sources of distress in such situations are suggested.

Design: Semistructured, open-ended interviews. Participants were asked to describe cases in which treatment had been provided primarily in response to demands from family members.

Participants: Six physicians and 6 nurses from 6 university-affiliated ICUs in Canada. All were members of a task force developing a multicenter policy to address demands for treatment, and physician members were heads of their ICUs.

Outcome measures: Systematic analysis of interview transcripts and synthesis of findings.

Results: Participants recalled 28 cases in which treatment had been provided at the insistence of family members. Many cases described were very distressing for both medical staff and family members. Consistently problematic areas included: (1) suffering of dying patients, (2) the marked distress of family members, and (3) a breakdown in the relationship between care providers and families.

Conclusions: Conflict with family members about decisions to limit life-sustaining treatment can be very stressful for health care providers. Three important areas that give rise to distress were identified in this study. These key sources of distress should be looked for. They could be addressed by: (1) identifying to family members the importance of minimizing suffering and ongoing bodily injury of patients at risk for dying, (2) by doing so addressing directly the distress of family members by the provision of emotional support, and when appropriate directed toward helping them accept that the patient is dying, and (3) pursuing efforts to maintain or create a good relationship with family members despite disagreement about the appropriateness of continuing life-sustaining treatment.