A Balancing Act: Experiences of Nurses and Physicians When Making End-of-Life Decisions in Intensive Care Units.

533791 research-article2014

CNRXXX10.1177/1054773814533791Clinical Nursing ResearchClinical Nursing ResearchMcAndrew and Leske

Article

A Balancing Act: Experiences of Nurses and Physicians When Making End-of-Life Decisions in Intensive Care Units

Clinical Nursing Research 2015, Vol. 24(4) 357–374 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773814533791 cnr.sagepub.com

Natalie S. McAndrew, MSN, RN, ACNS-BC, CCRN1 and Jane S. Leske, PhD, RN, ACNS-BC1

Abstract The purpose of this qualitative, descriptive study was to describe endof-life decision-making experiences as understood by critical care nurses and physicians in intensive care units (ICUs). A purposive sample of seven nurses and four physicians from a large teaching hospital were interviewed. Grounded theory analysis revealed the core category of “end-of-life decision making as a balancing act.” Three interacting subthemes were identified: emotional responsiveness, professional roles and responsibilities, and intentional communication and collaboration. Balancing factors included a team approach, shared goals, understanding the perspectives of those involved, and knowing your own beliefs. In contrast, feeling powerless, difficult family dynamics, and recognition of suffering caused an imbalance. When balance was achieved during end-of-life decision making, nurses and physicians described positive end-of-life experiences. The consequence of an imbalance during an end-of-life decision-making experience was moral distress. Practice recommendations include development of support

1Froedtert

Hospital, Milwaukee, WI, USA

Corresponding Author: Natalie S. McAndrew, Clinical Nurse Specialist for the Medical Intensive Care Unit, Froedtert Hospital, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA. Email: [email protected]

Downloaded from cnr.sagepub.com at UNIV OF VIRGINIA on June 5, 2016

358

Clinical Nursing Research 24(4)

interventions for nurses and physicians involved in end-of-life decision making and further research to test interventions aimed at improving communication and collaboration. Keywords nurses, physicians, end-of-life, decision making

A Balancing Act: Intensive Care Unit (ICU) End-of-Life Decision Making Health care is increasingly becoming technologically advanced, creating complicated end-of-life decisions for patients, families, and providers (Juzuit, 2000). Statistics show that one of five patients admitted to the ICU die, and many of these deaths are the result of withholding or withdrawing life-support measures (Espinosa, Young, & Walsh, 2008). A unique challenge for health care providers is that less than 5% of ICU patients are able to make decisions about their treatment (Carlet et al., 2004). Intensive care patients’ inability to make their own treatment decisions in combination with a small number of advanced directives and patient–provider discussions about patient wishes for life-sustaining treatment (Carlet et al., 2004) often places family members in the role of patient spokesperson (Shanawani, Wenrich, Tonelli, & Curtis, 2008; White, Braddock, Bereknyei, & Curtis, 2007). Despite the importance of open discussions about end-of-life decisions, poor communication among physicians, family decision makers, and nurses can create conflict about treatment decisions (Puntillo & McAdam, 2006; Shanawani et al., 2008; White et al., 2007).

Background The possibility that life supportive technology lengthens the process of dying or could prolong patient suffering is distressing for health care professionals (Callahan, 2000; Ferrell, 2006; Robinchaux & Clark, 2006). Yet, withholding advanced medical support when such resources are available may seem unethical to some nurses and physicians (Callahan, 2000). An atmosphere of uncertainty is created in the ICU when the efficacy of life-support measures for a patient care situation is indefinite. Intensive care nurses and physicians have identified end-of-life decision making as one of the most common sources of ethical conflicts encountered in their clinical practice (Cronqvist & Nystrom, 2007; Puntillo & McAdam, 2006).


McAndrew and Leske

359

Research findings provide some evidence that differing perspectives of nurses and physicians is a source of potential conflict and a possible barrier to communication and collaborative processes (Espinosa et al., 2008; Hamric & Blackhall, 2007; Puntillo & McAdam, 2006). This raises important questions about how nurses and physicians share their perspectives during end-oflife decision making and the possible influence of these professional perspectives on the decision-making process.

Purpose The aim of the current study was to understand nurses’ and physicians’ perspectives and experiences with end-of-life decision making. The specific research question was as follows: Research Question 1: How do intensive care nurses and physicians describe their experiences with end-of-life decision making?

Method Design/Setting/Sample A descriptive, qualitative design based on grounded theory methods by Strauss and Corbin (1998) was used for this study. ICUs in a large academic, Magnet® designated, Midwestern hospital were the research setting. All types of ICUs were included (surgical, medical, neurological, and cardiovascular) because end-of-life decision making occurs in all areas of critical care practice. A purposive sampling method was used. An inclusion criterion for nurses was current employment in an ICU as a registered nurse. Both novice and expert nurses were enrolled in the study. New graduate nurses were excluded because they have minimal experience as independent practitioners. The inclusion criterion for physicians was practice experience in the ICU setting. Physicians with various levels of education (residents, fellows, and attending physicians) and years of experience in critical care practice were recruited. Residents nearing the end of their clinical rotation in the ICU were excluded, as they may be practicing outside of the ICU at the time of the study. There were 11 participants in the study. Interviews were conducted with seven nurses (6 female, 1 male) from surgical, neurosciences, cardiovascular, and medical ICUs and four attending physicians (2 male, 2 female), who all practiced in a medical ICU. All nurses were baccalaureate prepared. The physicians all specialized in critical care medicine and were board certified in this area. The nurse and physician participants’ years of experience within


360


their respective professional roles ranged from 1 to 33 years. The sample reflected a diverse composition of participants of various ages.

Ethical Considerations, Recruitment, and Data Collection This study was approved by the Institutional Review Board for the protection of Human Subjects, and written informed consent was obtained from all participants. Flyers were placed with the inclusion criteria in the ICU staff restrooms and break rooms in the hospital. An interview guide was developed from review of the literature (the appendix). One-on-one unstructured interviews with critical care nurses and physicians were conducted with one member of the research team. Interviews were digitally audio-recorded and uploaded into a computer file. The interviews lasted 19 to 65 min and took place in a setting of the participant’s choosing. Field notes were used to capture participant behaviors and nonverbal communication.

Data Analysis/Rigor and Determination of Trustworthiness The digitally audio-recorded interviews were transcribed, and played multiple times with transcripts in hand to check for accuracy. All transcripts were coded during the process of line-by-line analysis of the data, and during this time sensitizing and theoretical questions were proposed, and potential concepts and categories were explored (Strauss & Corbin, 1998). Data collection and analysis was an iterative process guided by memos, diagrams, and axial coding. Categorical and theoretical comparisons were posed. After data coding, a central category, categories, and subcategories were identified to derive a theoretical scheme/preliminary theory. A professor of nursing with expertise in grounded theory methodology guided the process and reviewed all analyses. To meet the requirement of credibility, peer debriefing was performed and a reflexive journal was kept to overcome judgments and emotions experienced during the interview process that may have affected the analysis of data. Nurses and physicians with various levels of experience were selected to support the transferability of the research findings. Dependability was addressed by having an expert review of all data and study findings. The criterion of confirmability was met by keeping a methodological journal that provided an audit trail.

Results The overarching theme found was end-of-life decision making is a balancing act. Three subthemes emerged: emotional responsiveness, professional role and responsibilities, and intentionally communicating and collaborating.


361

McAndrew and Leske

Factors that balance end-of-life decision making: Team approach/shared goals Understanding perspectives Knowing own beliefs

Professional role and responsibilities

Emotional responsiveness

Balance: Positive end-of-life experiences

Intentional communication and collaboration

Factors that cause imbalance during end-of-life decision making: Uncertainty Feeling powerless Difficult family dynamics Recognizing suffering

Imbalance: Moral distress

Figure 1. Conceptual map of end-of-life decision making as a balancing act.

Certain factors balanced the end-of-life decision-making process, and other factors caused an imbalance. Although subthemes are discussed independently, it is acknowledged that they interact and are concurrent in practice. Figure 1 illustrates the decision-making process and related subthemes/balancing factors.

End-of-Life Decision Making: A Balancing Act Nurses and physicians described various elements of end-of-life decision making, and acknowledged that it was a process that could be challenging, as well as rewarding. The overarching theme, or central category that end-of-life decision making is a balancing act, was derived from nurse statements of “it’s kind of off balance” and “a weight is lifted off your conscience” and physician statements such as “emotional tug of war” and “weighing all the factors.”

Emotional Responsiveness Despite nurses’ and physicians’ intentions to keep emotions, feelings, and opinions out of decision making, the concept of emotional responsiveness


362


was an important aspect of most participants’ experiences. Emotional responsiveness was related to understanding and responding to the human condition. Influential factors included personal beliefs about quality of life, patient and family beliefs about quality of life, feeling a connection with patients and families, and personal and professional experiences with end-of-life decision making, death, and dying. The following nurse narrative about a patient who became an organ donor illustrates this subtheme: It was this horrible emotion . . . I progressively went from overwhelmed to just saddened . . . her room was just covered in pictures of her and she was a teacher, and you look at the pictures, and you look at the patient and it doesn’t even look like the same person.

A physician shared, “You are kind of reminded that you are dealing with people, human beings . . . you realize that your emotions are being played with.” It was very important for nurses and physicians to keep their emotions separated from their professional actions while caring for patients and families in the ICU. A nurse shared how she functioned in her professional practice when she did not agree with a patient or family’s beliefs about quality of life: I basically become indifferent. Close my mouth. Because my opinion in those situations matters but it doesn’t . . . if a family is stark fast on an idea it’s not my place to change their beliefs. So basically, I just become very objective, um numbers, infections, you know very methodical in I pull my emotional side out of it and I am then just a nurse taking care of a patient and helping the family, but just being the nurse.

A physician shared, When you are a young physician you really feel like you are going to be able to save everybody and realizing that you can’t, you just can’t understand why anyone would doubt you. You get that resistance going where you feel emotional about your decision, and you are emotional about the fact that somebody doesn’t agree with your decision.

Professional Role and Responsibilities Nurses described their responsibilities in end-of-life decision making as bringing all people involved in the decision together, sharing information with and about the patient and family, and assuring the patient and family’s


McAndrew and Leske

363

comfort. Nurses believed that their role in end-of-life decision making was to serve as a patient and family advocate. A nurse shared her act of advocacy: . . . Unless you are going to grow this girl a new pair of lungs, you need to talk to the family, she needs to be put on a morphine drip and she will quietly pass away. I am not going to watch her cry and sob and beg me to put her on the ventilator. And the intern then said, well this is what our plan is. And I said, well then go carry out your plan . . . I am NOT doing this. And they did make her a no code shortly after and she did die.

For this nurse, preventing patient suffering was an important advocacy behavior, and by not engaging in a plan of care that caused suffering, she was able to sway the physicians to modify treatment goals. Nurses consistently shared their knowledge about patients and families with those who had the ability to influence the treatment plan (physicians). Physicians described their responsibilities in end-of-life decision making as seeking out information about patients and families, presenting treatment options, and advocating for patients. Information learned about patients and their family members played a crucial role when physicians considered what treatment options to present to patients and families. A physician explained, . . . Often in critical care medicine, as you know, we haven’t had a chance to learn much about who the person was or what he, she wanted. But to get information about what their feelings about what the end of life would be so that we can then serve best in an advisory capacity . . .

Physicians discussed the importance of helping family members not feel as though they are “stuck, or saddled” with a decision. Nurses and physicians described a shared goal, which was to help patients and families find some kind of acceptance in terms of the decisions made. Another important professional behavior expressed by nurses and physicians was the concept of presence. Presence was being with the patient and family at the bedside for nurse participants, and for physicians, it was being available to the patient and family. Both professionals served as patient and family advocates. However, how they advocated for patients and families differed, such that their actions usually fell into their respective scopes of practice. Nurses advocated by helping patients and families feel heard and questioning treatment decisions that may contribute to patient suffering. Physicians advocated by helping families come to terms with treatment decisions. The motivation behind nurses’ and physicians’ advocacy behaviors was to avoid or minimize patient suffering.


364


Intentional Communication and Collaboration The professional behaviors of communication and collaboration are an essential part of end-of-life decision making. It was important for nurses and physicians to engage in intentional communication and collaboration, in which they shared knowledge, information, and concerns about a plan of care with fellow nurses, physicians, patients, and family members. Intentional communication is an important distinction. Nurses and physicians constantly communicate and interact in practice; however, everyday interactions did not consistently meet the goal of shared decision making. Thus, when a nurse or a physician had a goal or a clear message to share, end-of-life decision making was better facilitated. A nurse explained, “ . . . we try to collaborate with the physicians to . . . kind of get them moving forward so we are all going in the same direction. I think as the nurse it’s important to have that communication.” For physicians, intentional communication and collaboration meant clear messages to families. When discussing family conferences, a physician explained, “ . . . That’s where the nurse can share a key piece of perspective and hopefully help the family members understand where we’re at.” Thus, intentional communication was needed to facilitate a collaborative approach to shared decision making. When elements of communication or collaboration were missing, or the quality of communication or collaboration was considered poor, nurses and physicians expressed frustration with the decision-making process. Certain factors made intentional communication and/or collaboration difficult. Some of these factors were uncertainty about a patient’s prognosis, lack of clear documentation of treatment goals to understand where the decision-making process was at, and inconsistent messages given to families by nurses and physicians. A nursing concern was “crisis decision making,” and nurses felt very strongly that end-of-life decision-making conversations did not occur as early as they should in practice. Physicians and nurses identified handoffs in care as a potential problem for communication as well, especially if patients or families were struggling with the decision-making process. Clear communication was a skill both professionals used when attempting to engage in collaborative end-of-life discussions. Intentional communication and collaboration were facilitated by early conversations with patients and families, detailed handoffs between physicians and nurses, consistent messages among nurses, physicians, patients, and families, knowing the people involved in the decision making, as well as specific communication and collaboration strategies—listening, teaching, learning, and role models. Palliative care consultation and critical debriefings about patient care events were identified as resources that also promoted intentional communication and collaboration.


McAndrew and Leske

365

Nurses and physicians described key behaviors that helped maintain balance in end-of-life decision making. These factors included a team approach and shared goals, understanding the perspectives of those involved, and knowing your own beliefs. A nurse explained what a positive end-of life decision making was like: We got all the people that were involved . . . the organ donation people, transplant surgery, doctors, chaplains, the nurses that were involved in the case. And we all went around in a circle and we talked about what it felt like for us to be involved in the care when that happened. So it’s usually a real positive thing. No finger pointing. There’s explaining of the rules . . . and you usually feel way better . . . like a weight is lifted off of your conscience.

A physician participant shared this about a team approach: I am (likely to consult palliative) . . . when you are also attending in the unit you really have so many roles you have to play that sometimes you’re not free to coordinate all these communication pieces into play. And I’ve found that that’s very helpful when you have another set of physicians and nurse practitioners . . . that whole team approach to be able to work with it. I know that they also have Chaplain Services that rotate with them as well as nursing. And so they have their own little micro team that is going to help support that process of communication and reaching decisions about how to promote comfort and care at end-of-life.

In contrast, some factors caused an imbalance during end-of-life decisionmaking situations, such as uncertainty about a patient’s prognosis, feeling powerless in the end-of-life decision-making process, difficult family dynamics, and recognizing patient or family suffering. A nurse shared this negative end-of-life decision-making experience: So . . . there wasn’t the communication which is absolutely imperative to having patients, families understand the death of their family member. And because they weren’t there, there was a lot of angst, there was a lot of yelling, there was threatening. There was this just horrible, horrible situation for this family, for the staff. Because that communication wasn’t there. That was torture.

A physician described this negative end-of-life experience: I think it’s more difficult for me personally when it’s someone I’ve known a long time, someone I know who has gotten through some difficult scrapes. And


366


then it becomes . . . and you know you’ve tried maybe harder than some other people might of to keep them going this long. Then personally, it’s very hard. Harder for me to say, you know I think. . .

Consequence of an Imbalance in End-of-Life Decision Making Nurses and physicians did not want to become emotionally invested in patient care situations and worked hard to perform their professional role and responsibilities. However, despite these efforts, this was not always possible. Nurse–physician communication and collaboration during end-of-life decision making did not always occur. The consequence of an imbalance among emotional responsiveness, professional role and responsibilities, and communicative or collaborative behaviors during end-of-life decision making was moral distress. A nurse shared, And I just think that’s kind of negative when I’m like doing CPR (cardiopulmonary resuscitation) on somebody that I know is not going to come back . . . I mean I’ll do it but I just get really sad and feel like . . . I just get emotionally . . . it kind of affects you. You get emotionally distressed about that. So . . . doing something that you know. CPR on a 90 year old and all you hear is cracking their ribs and you are just like why am I doing this?

The physician experience of moral distress was also recognized in the narratives. A physician explained, You feel like when you deal with chronic illness that’s not getting better . . . there are times when I question . . . you know what have I done? That’s probably the whole nature of it . . . unless I was a dermatologist. I go up and down but I think doing it part-time let’s me cope with it. But it’s the end-of-life issues and helping those families through that and being able to spend the time . . . there’s 16 patients on your service and a lot of families that want to sit down and hear about what’s going on. It’s tiring and draining. And then if you get into these battles about end-of-life it gets really exhausting. It does wear me out. I get tired. There are times when I’ve had enough.

Discussion The core category of end-of-life decision making as a balancing act is comparable with concepts described in several qualitative studies (Bach, Ploeg, & Black, 2009; Cronqvist, Theorell, Burns, & Lutzen, 2004; Lutzen, Cronqvist, Magnusson, & Andersson, 2003). In Bach et al.’s (2009) study on


McAndrew and Leske

367

the role of critical care nurses during end-of-life decision making, the nursing behavior of truth telling was identified. When nurses had to articulate the truth about a patient care situation, they had to find a way to balance honesty with hope. Similarly, Cronqvist et al. (2004) found that nurses were able to balance their moral obligations and work-related responsibilities by understanding the perspectives of others involved in the situation. End-of-life decision making is about morals, choices, feelings, perceptions, experiences, and these must be considered and weighed within the context of professional responsibilities and demands (Bach et al., 2009; Cronqvist et al., 2004; Lutzen et al., 2003). Nurses and physicians are committed to doing what they think is right for patients, but it is important to acknowledge that a moral imperative of what is right is imbedded in one’s beliefs and knowledge about ethics (Lutzen et al., 2003; Pellegrino, 2006). Critical care nurses and physicians in the current study were confronted with ethical conflicts and what Lutzen et al. (2003) defined as moral choices and demands. Although the nursing and medical professions have different scopes of practice and frameworks that define their roles and responsibilities, they share a common experience of being close to death and dying regularly, and serve as support persons for patients and families. Nurses and physicians had a shared goal, which was to help patients and families through the process of end-of-life decision making. Physicians wanted to “bear the burden” for families, so that they did not feel as though they were making a decision about life or death, while nurses tried to reinforce information and serve as a “sounding board” for families concerns about a plan of care. Research has shown that some of the factors that influence nurse–physician collaboration include differences in communication behaviors/styles (Coeling & Cukr, 2000; Manojilovich & Antonakos, 2008), the kind of information and knowledge used in problem solving (Stein-Parbury & Liaschenko, 2007), hierarchical relationships (Cobanoglu & Algier, 2004; Sirota, 2007, 2008; Stein-Parbury & Liaschenko, 2007), differing beliefs about responsibilities, barriers, and solutions to collaborative practice (Rosenstein, 2002), and dissimilar definitions of collaboration (Casanova et al., 2007). In the current study, some challenges that occurred from the nursing perspective with collaborative practice were related to experiences in which nurses felt that they were not heard by physicians, or were “chasing down” physicians to engage them in a discussion about the plan of care. In addition, when nurses felt that they did not know some of the attending physicians, they felt intimidated in nurse–physician interactions. Nurses focused on how they communicated and collaborated with physicians in their narratives, while physicians discussed communication with families. In contrast,


368


physicians did not describe any experiences in which they had difficulty communicating or collaborating with nurses. Physicians focused on challenges communicating with families. Transitions from curative to palliative care can sometimes be difficult and may not always incorporate principles of holistic care (Pattison, 2004). Badger (2005) examined nurses’ perspectives of actions that enabled or inhibited a transition from aggressive care to palliative-oriented approaches. Participants identified physician inconsistency with approaches to end-of-life decisions, poor communication, and lack of respect for patient wishes as hindrances to moving toward palliative care. Similarly, in the current study, nurses discussed frustrations in transitions of care, and emphasized that conversations about end-of-life should occur early on. Some nurses in the current study felt that patient wishes were sometimes an afterthought, making the integrated palliative/cure culture feel unattainable. Communication was recognized as being problematic at times, and nurses and physicians were concerned that families did not fully understand the options that were presented to them. A united front created from shared decision making that produces clear, consistent messages for families was identified by the nurses and physicians in the study as a way to improve the decision-making process. Nurses emphasized that collaboration was important to them, and that they wanted to have input during the decision-making process. Nurses experienced moral distress, and these narratives were related to an inability to influence an end-of-life decision. Nurses articulated a sense of powerlessness because it seemed as though the physician was not listening to the nurse or the patient/family. Similarly, in a study about nursing ethical conflicts Ferrell (2006) found that when nurses were unable to influence ethical conflicts they described feeling powerless and demoralized. Browning (2013) examined critical care nurse empowerment in the workplace and found that moral distress frequency was negatively correlated with empowerment scores. In another descriptive study looking at the possible effect of moral distress on the professional practice environment, moral distress frequency and intensity were negatively related to collegial relationships with physicians (McAndrew, Leske, & Garcia, 2011). Thus, nurses overall feelings of professional empowerment, as well as their relationships with physicians, may influence their experience of moral distress. Physicians articulated distress when family expectations were incongruent with patient prognosis. Ahern, Doyle, Marquis, Lesk, and Skrobik (2012) interviewed senior medical residents about their experiences with end-of-life decision making. Themes included desire to respect patient wishes, balance between family wishes and appropriateness of care and professionalism toward patients. When families pressured the ICU team to


McAndrew and Leske

369

continue treatment despite a poor prognosis, the physicians interviewed articulated a sense of helplessness. Similarly, in the current study physicians interviewed were concerned about causing patient suffering when care was deemed futile, and treatment would only prolong the dying process. Physicians were frustrated with family dynamics that led to unrealistic expectations and demands, and these situations caused some moral distress.

Limitations This research was conducted in a large academic-based hospital located in a Midwestern metropolitan area and would not capture the experiences of nurses and physicians in different practice environments. Another limitation is a threat to credibility, as the researchers had a professional relationship with some of the participants in the study. A purposive sampling technique was implemented; however, nurse participants were all bachelor’s prepared, and thus, the experiences of nurses with associate degree or diploma training may be different and are not represented in these findings. In addition, all physicians interviewed were attending physicians, and the experiences of fellows and residents were not captured. Although multiple attempts were made to recruit physicians to the study, there was not enough participation to achieve theoretical saturation. Therefore, findings represent only preliminary theory that requires further research to validate and expand into substantive theory. A wide range of experiential practices were observed in the nurse and physician participants. How experiential practice influenced end-of-life decision making was not part of this research study. In addition, advanced directives and moral beliefs may affect end-of-life decisions, but were not explored in the current study. Further research is needed to clarify the role these factors may play in end-of-life decision making.

Application to Clinical Practice Nurses and physicians need support with end-of-life decision making. Evidence exists that nurses are not satisfied with communication processes during end-of-life decision making (Badger, 2005; Oberle & Hughes, 2001; Robinchaux & Clark, 2006). The result of a nurse’s inability to advocate and realize patient care goals can cause symptoms of moral distress (American Association of Critical Care Nurses, 2006). In addition, the effect of a nurse’s unresolved moral distress can influence patient outcomes by way of the nurse withdrawing from patient care (Gutierrez, 2005), leaving a nursing specialty,


370


or even the nursing profession itself (Corley, Minick, Elswick, & Jacobs, 2005; Pendry, 2007; Rushton, 2006). Patients and families need compassionate, emotionally present nurses and physicians engaged in their care. Nurses and physicians need to acknowledge conflicts and problems that occur during end-of-life decision making by discussing perspectives and work collaboratively to resolve issues as a team. When this does not occur, nurses may turn their frustrations toward physician decisions, and physicians may become frustrated with those who question their decisions (Oberle & Hughes, 2001; Simmonds, 1996; Viney, 1996). These professional frustrations can hinder decision-making processes and negatively affect patient and family outcomes (Oberle & Hughes, 2001; Puntillo et al., 2001; Rosenstein, 2002). Developing and maintaining support (education, shared decision-making teams, debriefings) for nurses and physicians who engage in end-of-life decision making regularly may improve endof-life experiences for all involved. In addition, interventions aimed at improving collaborative practice may increase critical care nurses satisfaction with their practice environments (Hamric & Blackhall, 2007) and keep them working in the critical care specialty. Moral distress in the literature has been nursing focused, and it is important to understand how physicians experience moral distress. In addition, understanding how the experience and sources of moral distress are similar or dissimilar in nurses and physicians may help develop more effective interdisciplinary interventions to target moral distress associated with nurse–physician conflict. The physician perspective is important and must be placed in the context of nurses’ views to fully understand professional communication and collaboration as it occurs in practice. There is a need for future research to address the effectiveness of interventions proposed to improve end-of-life decision making. Interdisciplinary collaboration is frequently cited as an intervention that can improve patient outcomes, quality of care, as well as job satisfaction among health care professionals (Coeling & Cukr, 2000; Puntillo & McAdam, 2006). The increasing amount of evidence that supports improved patient outcomes through collaborative practice cannot be ignored (Stein-Parbury & Liaschenko, 2007; Zwarenstein & Bryant, 2000). Imbedded into collaborative practice are nurse–physician relationships. The quality of these relationships affect nursing practice environments and subsequently, the nursing care delivered (Aiken, Clarke, Sloane, Lake, & Cheney, 2008). The current study has provided some evidence about the experiences of nurses and physicians with end-of-life decision making. Future research is needed to understand if the findings in this study are applicable to other practice environments and further develop analysis into substantive theory.


McAndrew and Leske

371

Appendix Interview Guide Each interview began with the question, When thinking about patients who are receiving all life supportive measures and are not improving, or situations in which patient death is imminent and re-evaluation of the goals of care becomes necessary, can you tell me about what these kinds of experiences and situations have been like for you as a physician or nurse?

Other interview questions and probes included the following: •• In your experience, how have end-of-life decisions been made? •• How have these experiences made you feel? •• Can you tell me about your perception of your professional role and responsibilities in these situations? •• Can you tell me about what it has been like for you to work with other professional health care team members during these kinds of situations? •• What is your perception of the roles and responsibilities of other professional health care team members during end-of-life decision making? •• When you are involved in an end-of-life decision, who do you involve and why? •• How do you communicate with other people involved in care of the patient during end-of-life decision making? •• From your perspective, what kinds of things in your professional practice have led to what you would describe as a positive experience with an end-of-life decision? •• From your perspective, what kinds of things in your professional practice have led to what you would describe as a challenging experience with an end-of-life decision? •• If you could describe an ideal end-of-life decision-making process, what would it be like? How would you describe your involvement in this ideal end-of-life situation? Who would be involved? Acknowledgment We would like to acknowledge the critical care nurses and physicians who shared their experiences with end-of-life decision making.


372


Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References Ahern, S. P., Doyle, T. K., Marquis, F., Lesk, C., & Skrobik, Y. (2012). Critically ill patients and end-of-life decision making: The senior medical resident experience. Advances in Health Science Education, 17, 121-136. Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital care environments on patient mortality and nurse outcomes. Journal of Nursing Administration, 38, 223-229. American Association of Critical Care Nurses. (2006). The 4 A’s to rise about moral distress [Brochure]. Retrieved from http://www.aacn.org/WD/Practice/ Docs/4As_to_Rise_Above_Moral_Distress.pdf Bach, V., Ploeg, J., & Black, M. (2009). Nursing roles in end-of-life decision making in critical care settings. Western Journal of Nursing Research, 31, 496-512. Badger, J. M. (2005). Factors that enable or complicate end-of-life transitions in critical care. American Journal of Critical Care, 14, 513-522. Browning, A. M. (2013). Moral distress and psychological empowerment in critical care nurses caring for adults at end of life. American Journal of Critical Care, 22, 143-151. Callahan, D. (2000). The troubled dream of life: In search of a peaceful death. Washington, DC: Georgetown University Press. Carlet, J., Thijs, L. G., Antonelli, M., Cassell, J., Cox, P., Hill, N., . . . Thompson, B. T. (2004). Challenges in end-of-life care in the ICU: Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Medicine, 30, 770-784. Casanova, J., Hendricks, B., Day, K., Theis, L., Dorpat, D., & Wiesman, S. (2007). Nurse-physician work relations and role expectations. Journal of Nursing Administration, 37, 68-70. Cobanoglu, N., & Algier, L. (2004). A qualitative analysis of ethical problems experienced by physicians and nurses in intensive care units in Turkey. Nursing Ethics, 11, 444-458. Coeling, H. V., & Cukr, P. L. (2000). Communication styles that promote perceptions of collaboration, quality, and nurse satisfaction. Journal of Nursing Care Quality, 14(2), 63-74. Corley, M. C., Minick, P., Elswick, R. K., & Jacobs, M. (2005). Nurse moral distress and ethical work environment. Nursing Ethics, 12, 381-390.


McAndrew and Leske

373

Cronqvist, A., & Nystrom, M. (2007). A theoretical argumentation on the consequences of moral distress. Journal of Nursing Management, 15, 458-465. Cronqvist, A., Theorell, T., Burns, T., & Lutzen, K. (2004). Caring about—Caring for: Moral obligations and work responsibilities in intensive care nursing. Nursing Ethics, 11, 63-76. Espinosa, L., Young, A., & Walsh, T. (2008). Barriers to intensive care unit nurses providing terminal care: An integrated literature review. Critical Care Nursing Quarterly, 31, 83-93. Ferrell, B. R. (2006). Understanding the moral distress of nurses witnessing medically futile care. Oncology Nursing Forum, 33, 922-930. Gutierrez, K. M. (2005). Critical care nurses’ perceptions of and responses to moral distress. Dimensions of Critical Care Nursing, 24, 229-241. Hamric, A. B., & Blackhall, L. J. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine, 35, 422-429. Juzuit, D. L. (2000). Suffering of critical care nurses with end-of-life decisions. Medical Surgical Nursing, 9(3), 145-152. Lutzen, K., Cronqvist, A., Magnusson, A., & Andersson, L. (2003). Moral stress: Synthesis of a concept. Nursing Ethics, 10, 312-322. Manojilovich, M., & Antonakos, C. (2008). Satisfaction of intensive care unit nurses with nurse-physician communication. The Journal of Nursing Administration, 38, 237-243. McAndrew, N. S., Leske, J. S., & Garcia, A. G. (2011). Influence of moral distress on the professional practice environment during prognostic conflict in critical care. Journal of Trauma Nursing, 18, 221-230. Oberle, K., & Hughes, D. (2001). Doctors’ and nurses’ perceptions of ethical problems in end-of-life decisions. Journal of Advanced Nursing, 33, 707-715. Pattison, N. (2004). Integration of critical care and palliative care at end of life. British Journal of Nursing, 13, 132-139. Pellegrino, E. D. (2006). Toward a reconstruction of medical morality. The American Journal of Bioethics, 6(2), 65-71. Pendry, P. S. (2007). Moral distress: Recognizing it to retain nurses. Nursing Economics, 25(4), 217-221. Puntillo, K. A., Benner, P., Drought, T. D., Drew, B., Stotts, N., Stannard, D., . . . White, C. (2001). End-of-life issues in the intensive care units: A national random survey of nurses’ knowledge and beliefs. American Journal of Critical Care, 10, 216-229. Puntillo, K. A., & McAdam, J. L. (2006). Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: Challenges and opportunities for moving forward. Critical Care Medicine, 34(11 Suppl.), S332-S340. Robinchaux, C. M., & Clark, A. P. (2006). Practice of expert critical care nurses in situations of prognostic conflict at the end of life. American Journal of Critical Care, 15, 480-489.


374


Rosenstein, A. H. (2002). Nurse-physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 102(6), 26-34. Rushton, C. H. (2006). Defining and addressing moral distress: Tools for critical care nursing leaders. American Association of Critical Care Nurses Advanced Critical Care, 17(2), 161-168. Shanawani, H., Wenrich, M. D., Tonelli, M. R., & Curtis, J. R. (2008). Meeting physicians’ responsibilities in providing end-of-life care. Chest Journal, 133, 775-786. Simmonds, A. (1996). Decision-making by default: Experiences of physicians and nurses with dying patients in intensive care. Human Medicine Health Care, 12(4), 168-172. Sirota, T. (2007). Nurse/physician relationships: Improving or not? Nursing2007, 37, 52-55. Sirota, T. (2008). Nurse/physician survey report. Nursing, 38(7), 28-31. Stein-Parbury, J., & Liaschenko, J. (2007). Understanding collaboration between nurses and physicians as knowledge at work. American Journal of Critical Care, 16, 470-478. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Thousand Oaks, CA: SAGE. Viney, C. (1996). A phenomenological study of ethical decision-making experiences among senior intensive care nurses and doctors concerning withdrawal of treatment. Nursing in Critical Care, 1, 182-189. White, D. B., Braddock, C. H., Bereknyei, S., & Curtis, R. (2007). Toward shared decision making at the end of life in intensive care units. Archives of Internal Medicine, 167, 461-467. Zwarenstein, M., & Bryant, W. (2009). Interventions to promote collaboration between nurses and doctors (review). Cochrane Database of Systematic Reviews, 3, 1-14. doi:10.1002/14651858.CD000072.pub2

Author Biographies Natalie S. McAndrew, MSN, RN, ACNS-BC, CCRN is the Clinical Nurse Specialist for the Medical Intensive Care Unit at Froedtert Hospital. Jane S. Leske, PhD, RN, ACNS-BC is a professor in the College of Nursing at the University of Wisconsin-Milwaukee and Nurse Scientist at Froedtert Hospital.


Shared decision-making in pediatric intensive care units: a qualitative study with physicians, nurses and parents.

Balancing professional tension and deciding upon the status of death: Making end-of-life decisions in intensive care units.

Family members' experiences of being cared for by nurses and physicians in Norwegian intensive care units: a phenomenological hermeneutical study.

Nurses' experiences of performing cardiopulmonary resuscitation in intensive care units: a qualitative study.

Ethical challenges in the neonatal intensive care units: perceptions of physicians and nurses; an Iranian experience.

Parental Sources of Support and Guidance When Making Difficult Decisions in the Pediatric Intensive Care Unit.

Ethical problems in intensive care unit admission and discharge decisions: a qualitative study among physicians and nurses in the Netherlands.

Nurses empathy and family needs in the intensive care units.

Intensive care nurses' experiences of end-of-life care.

Psychosocial determinants of self-reported hand hygiene behaviour: a survey comparing physicians and nurses in intensive care units.

Family visitation in greek intensive care units: nurses' perspective.

A burden of knowledge: A qualitative study of experiences of neonatal intensive care nurses' concerns when keeping information from parents.

End-of-life decisions in intensive care medicine-shared decision-making and intensive care unit length of stay.

Exploration and classification of intensive care nurses' clinical decisions: a Greek perspective.

Intensive care unit patients in the postanesthesia care unit: a case study exploring nurses' experiences.

The congruence of nurses' performance with developmental care standards in neonatal intensive care units.

Psychosocial factors and mental work load: a reality perceived by nurses in intensive care units.

Clinical Alarms in Intensive Care Units: Perceived Obstacles of Alarm Management and Alarm Fatigue in Nurses.

Surgeons and intensive care units.

A standardized shift handover protocol: improving nurses' safe practice in intensive care units.

End-of-life decisions in Burn Intensive Care Units - An International Survey.

Delirium assessment in intensive care units: practices and perceptions of Turkish nurses.

Attitudes Toward and Experiences in End-of-life Care Education in the Intensive Care Unit: A Survey of Resident Physicians.

Care bundles in intensive care units.