Caregiver and Family Dynamics
It is well documented in the literature that disorders such as anxiety, posttraumatic stress disorder, and depression are issues for families or caregivers who experience a death in the ICU setting. What is also recognized is that family involved in any high-risk illness in the ICU or in end-of-life decision making begins experiencing distressing feelings or this anxiety in the midst of the care event. In the case of L.S., it was clear that his wife was struggling between her own anticipatory grief and the need to protect herself and her children and her need to honor her husband's stated wishes. She acknowledged to the team that because of her helpless feelings related to his disease and prognosis, she felt this was the last element of control that she maintained. It is not uncommon for nurses and team members to mistakenly see this as "selfish" and not as a coping strategy for the family. It seemed to the team that she perhaps did not understand the terminal nature of his illness and the recommended path of a comfort-directed plan of care, which then led to feelings of frustration and hostility toward her by the staff. Many people look at this as denial, but in fact it is a common way of coping or protecting one's self from the burden that is upon them.
Identifying and then resolving conflict among staff and family can be challenging. There are several different conflict resolution strategies reported in the literature including dominating, obliging, avoiding, compromising, and integrating. The nursing literature reports that nurses predominantly use avoidance as their strategy. In the case presented here, this avoidance was toward the patient's family and could potentially lead to the family feeling isolated at an extremely vulnerable time. Avoidance can also be seen as a protective mechanism for the staff to decrease the internal struggles they are going through related to a patient care plan.
To decrease stress and conflict among both parties, the literature supports utilizing open and frequent communication, family meetings, and shared decision making and involving palliative care or other support services as mechanisms to prevent or reduce the incidence of posttraumatic stress disorder or long-term depression. These methods of involving family from the outset of the critical illness can help them see the decline as a process or trajectory and prepare them for possibilities of recovery or an ultimate decline and death. This can help decrease or eliminate the surprise factor of the patient not responding to treatment, and support mechanisms can be put in place earlier to assist the family.