Abstract and Introduction
Abstract
Nurses are in a pivotal position to improve care for dying patients and their families by challenging current end-of-life practices in their settings. However, nurses report a lack of preparation in dealing with end-of-life (EOL) care in the intensive care environment. The aims of the study were to explore nurses' definitions of quality EOL care and to identify the personal, environmental, and relational factors that facilitate or inhibit the nurses' ability to provide EOL care to patients and their families. Nine critical care nurses were interviewed about their values and beliefs related to providing quality EOL care. Interviews were audiotaped, transcribed, and analyzed for themes and patterns. Using Bowen's model of value-behavior congruency, several themes were identified and were examples of personal, environmental, and relational factors that facilitate or hinder critical care nurses' ability to provide quality end of life. Nurses used strategies such as "balancing," "trial and error," "coaching the physicians," and "taking a step back" to improve the quality of EOL care provided. The values and behaviors as well as the personal, environmental, and relational factors identified in this study may be useful in determining factors related to providing quality nursing care at the end of life.
Introduction
The Institute of Medicine defined optimum end-of-life (EOL) care as an experience that is free from avoidable distress and suffering for patients and their families, in accord with the patients' and families' wishes, and reasonably consistent with clinical, cultural, and ethical standards. Standards for a good death include symptom management, patient- and family-focused care, and spiritual well-being for both patients and families. The World Health Organization has defined quality EOL care as the "active total care of patients whose disease is not responsive to curative treatment." This definition includes meeting the psychological, social, and spiritual needs for both patients and families, as well as the definitions of quality care provided by the National Consensus Project and National Quality Forum summary.
Remarkable advances in medicine have changed how, when, and where people die. Instead of being viewed as a natural event in life, death is now managed as a disease that must be treated and "cured." Today, Americans develop an average of 2.2 chronic conditions and live with these conditions for an average of 17 years. Individuals experiencing exacerbations from these chronic conditions are rescued from death by sophisticated technological interventions in critical care units. In the critical care unit, the biomedicalization of death has removed the patient and family from the dying experience. Patients and families are often unaware that death is approaching and thus cannot prepare for it.
In the critical care unit, for the most part, death is no longer treated as a natural outcome of life but instead viewed as a medical failure. Often, the delivery of care in the critical care setting is so focused on saving the life of the individual that the quality of the life saved and the pain and suffering inflicted to save the life are ignored. The focus on medical cure in the intensive care setting often involves healthcare providers visualizing the patient as a disease or condition, rather than an individual with values, beliefs, and desires. This pathophysiological focus results in the values, beliefs, and desires of the patient being forgotten, and the patient-centered care that is desired by patients and families is not achieved in the critical care setting. Nurses who desire to provide quality EOL care must include patients and families in the decision-making process as well as helping them navigate through the technology of the ICU. Identifying nurses who are able to achieve a patient-centered focus can improve the quality of dying for individuals as well as improve patient, family, and provider satisfaction.