At the end: A vignette-based investigation of strategies for managing end-of-life decisions in the intensive care unit

Abstract

Background Decision-making on end-of-life is an inevitable, yet highly complex, aspect of intensive care decision-making. End-of-life decisions can be challenging both in terms of clinical judgement and social interaction with families, and these two processes often become intertwined. This is especially apparent at times when clinicians are required to seek the views of surrogate decision makers (i.e., family members) when considering palliative care. Methods Using a vignette-based interview methodology, we explored how interactions with family members influence end-of-life decisions by intensive care unit clinicians ( n = 24), and identified strategies for reaching consensus with families during this highly emotional phase of care. Results We found that the enactment of end-of-life decisions were reported as being affected by a form of loss aversion, whereby concerns over the consequences of not reaching a consensus with families weighed heavily in the minds of clinicians. Fear of conflict with families tended to arise from anticipated unrealistic family expectations of care, family normalization of patient incapacity, and belief systems that prohibit end-of-life decision-making. Conclusions To support decision makers in reaching consensus, various strategies for effective, coherent, and targeted communication (e.g., on patient deterioration and limits of clinical treatment) were suggested as ways to effectively consult with families on end-of-life decision-making.

Should parents be asked to consent for life-saving paediatric interventions?

“…through utilising JW liaison officers or chaplains). 26 While studies have reported that staff experience greater moral distress when patients are overtreated rather than undertreated, 27,28 being externally constrained from providing clinically indicated and routine lifesaving care might cause particular difficulty. To minimise the effect of staff distress, hospitals would do well to follow recommendations from the Guidelines for the Provision of Intensive Care Services, ensuring that a qualified psychologists are available to aid staff, patients, and their families.…”

Rethinking ‘Westernised’ medical ethics in end-of-life care

“…These govern how we do right by our patient, but they might also lack the finesse required to incorporate religion, faith and conflict. The work by Reader et al reminds us of the need not to discount the overarching influence of spirituality and religion, 2 and we believe there is a need for us all to be more informed in this regard. Sometimes, these principles can even feel too Westernised and of less relevance to the relatives and loved ones of our patients.…”

“…The recent qualitative study from Reader et al brings out several themes around end-of-life care in ICU that we believe have not yet been addressed sufficiently. 2 Whilst 'good communication' with families is often described as important, defining exactly what this involves is problematic, and getting these discussions right is an art that we all labour at for a lifetime.…”