Valdosta State University
School of Nursing
Dr. Maura Schlairet
Nov 23, 2008
Intensive care units (ICUs) were designed to provide highly skilled, lifesaving nursing care to viable patients with acute illnesses or injuries. Patients with chronic and/or terminal illness were not expected to be admitted to these units, with the possible exception of acute exacerbations of reversible complications. Patients whose care needs changed from curative to palliative were intended to be transferred out of critical care to patient care environments more suited to end-of-life care. However, as more patients become “chronically critically ill”, critical care nurses are being asked more often to provide care to patients on their deathbeds (Puntillo et al., 2001). Deciding which ICU patients are actually dying remains an extremely inexact science, and the transition to palliative care is not one easily made. ICU mortality rates are as high as 69% (Puntillo et al., 2001); almost 20% of Americans die in intensive care units (Hodde, Engelberg, Treece, Steinberg, & Curtis, 2004). The majority of patients who die in ICU have had DNR orders written, many of them within a day or two of their deaths. There are a number of reasons these patients are not transferred out: it may be too disruptive to the patient and/or family; there may be no appropriate bed available; or the level of care may still be such that a med/surg or hospice-type floor is not equipped or staffed to handle it (Puntillo et al.). Evidence shows that end-of-life care in ICUs is highly inconsistent, indicating that caregivers are not in agreement on how best to care for this patient population. There is evidence that dying patients experience inadequate relief of pain and other undesirable symptoms, and also that their wishes concerning end-of-life care are not always taken into account (Hodde et al.) Most ICU nurses did not enter their specialty because they enjoyed caring for patients that have no hope of recovery, and now they find themselves being called on to provide end-of-life care in what is often the worst possible setting. It has been my experience that many ICU nurses feel that they have not provided their patients with the best possible death for a variety of reasons. Many feel unprepared to give end-of-life care if it does not involve resuscitation, and feel unsupported in their attempt to provide quality palliative care in the high-tech environment of the ICU. I am proposing a research study that would investigate the experiences and attitudes of critical care nurses about providing end-of-life care in the ICU environment. Review of the Literature
In her article Nursing Knowledge for the 21st Century: Opportunities and Challenges (2000), Ada Sue Hinshaw identifies end-of-life research as one of the major fields of clinical study in which nurses need to be heavily involved. This research needs to include not only approaches to palliative care but also end-of-life decision making for patients and families, identification of transition phases, and what is important to patients and families during their end-of-life experience. In 2004, Bryce et al. conducted a study to determine how much healthy living time people would trade for quality end-of-life care in four areas: pain and discomfort, daily surroundings, treatment decisions and family support. Three-quarters of the subjects were willing to trade an average of 7.5 months of healthy living for a better end-of-life experience, indicating that quality end-of-life care is highly valued. However, while it is clear that patients and families want to have quality end-of-life care, most don’t want it quite yet – thus the transition from curative to palliative care is usually fraught with tension and uncertainty on the part of patient, family, and caregivers. The Robert Wood Johnson Foundation Critical Care End-of-Life Peer...