OBJECTIVE: To investigate the knowledge, beliefs, and ethical concerns of nurses caring for patients dying in intensive care units. METHODS: A survey was mailed to 3000 members of the American Association of Critical-Care Nurses. The survey contained various scenarios depicting end-of-life actions for patients: pain management, withholding or withdrawing life support, assisted suicide, and voluntary and nonvoluntary euthanasia. RESULTS: Most of the respondents (N = 906) correctly identified the distinctions among the end-of-life actions depicted in the scenarios. Almost all (99%-100%) agreed with the actions of pain management and withholding or withdrawing life support. A total of 83% disagreed with assisted suicide, 95% disagreed with voluntary euthanasia, and 89% to 98% disagreed with nonvoluntary euthanasia. Most (78%) thought that dying patients frequently (31%) or sometimes (47%) received inadequate pain medicine, and almost all agreed with the double-effect principle. Communication between nurses and physicians was generally effective, but unit-level conferences that focused on grief counseling and debriefing staff rarely (38%) or never (49%) occurred. Among the respondents, 37% had been asked to assist in hastening a patient's death. Although 59% reported that they seldom acted against their consciences in caring for dying patients, 34% indicated that they sometimes had acted against their conscience, and 6% had done so to a great extent. CONCLUSIONS: Intensive care unit nurses strongly support good pain management for dying patients and withholding or withdrawing life-sustaining therapies to allow unavoidable death. The vast majority oppose assisted suicide and euthanasia. Wider professional and public dialogue on end-of-life care in intensive care units is warranted.
BACKGROUND: Factors that can lead to breakdown in the care of the families of patients in the ICU include gaps in the healthcare providers' education and skill in working with families, unclear lines of responsibility for various aspects of family care, and insufficient support or supervision for the difficult emotional work of family care. OBJECTIVE: The purpose of this study was to highlight instances in which negative or difficult aspects of nursing care of family members of ICU patients were evident, so that needed changes in caring for the families could be emphasized. METHOD: Interpretive phenomenology was used to analyze transcribed audiotape recordings of interviews with 130 nurse participants and clinical observations of 48 nurse participants. The interpretive account is based on more than 100 narratives of patient care relayed in interviews and on observational notes that focused on care of the family. RESULTS: The five general nursing approaches that constrained family care in ICUs were nurses' efforts to (1) distance the family physically from the patient and the patient's bedside, (2) distance themselves from the patient and the patient's family, (3) characterize the family's perspective as pathological, (4) dissipate responsibility for family care, and (5) take an elemental rather than a systemic perspective. CONCLUSIONS: The breakdowns in family care observed in this study were neither new nor unique. In order to truly realize a patient- and family-focused healthcare system, an infusion of knowledge and skill must occur at the bedside with individual nurses.
BACKGROUND: Acute pain is a significant problem in critical care patients. Although many barriers to successful assessment and management of pain in critical care patients have been noted, little is known about how critical care nurses make clinical judgments when assessing and managing patients' pain. OBJECTIVE: This qualitative analysis is part of a pilot study evaluating nurses' use of a pain assessment and intervention notation algorithm in patients in critical care areas who have limited communication abilities after abdominal or thoracic surgery. METHOD: Transcribed audiotapes of nurse participants' "thinking aloud" while using the pain assessment and intervention notation algorithm were analyzed by using interpretive phenomenology. The interpretive account is based on 31 tape recordings of 14 nurses caring for 41 patients (12 patients in the ICU and 29 patients in the postanesthesia care unit). FINDINGS: The two domains of clinical judgment found were (1) assessing the patient and (2) balancing interventions. CONCLUSIONS: Many nurses' reports showed that they accurately assessed their patients' needs for analgesics. Through testing of and learning from their patients' responses, nurses were able to give amounts of analgesics that diminished patients' postoperative pain. Additionally, nurses had to balance analgesic administration against the patients' hemodynamic and respiratory conditions, medical plan and prescriptions, and the desires of the patients and the patients' families.