Critical Care Nurses' involvement in end-of-life decision-making: a grounded theory study
In critical care end-of-life care is a process that occurs in stages, which can vary in duration. It is the domain of nurses, while involvement in decision-making is less defined and based more on the individual nurse and the choices they make. The aim of this study was to examine the influence critical care nurses have on end-of-life decision making and care in New Zealand, using the grounded theory methodology of Corbin and Strauss. Nine critical care nurses working in a large tertiary hospital were interviewed and asked about their role in the process of decision-making. The research found that critical care nurses are vital to the joint processes of end-of-life decision-making and end-of-life care. In terms of their role, balancing the needs of both the patient and their family featured strongly, along with recognition that a patient was dying, transitioning from cure to comfort, utilising strategies to stay engaged and facilitating a good death. Participants described changing the environment once end-of-life care began. Moving into a side room marked a different approach to care, one that involved fewer interventions and greater access for family and friends. Seeing death as a failure was rejected in favour of letting go, that courage means negotiating dying with dignity, and not losing a battle with fear.
The grounded theory of Corbin and Strauss, underpinned by symbolic interactionism supported the researcher in formulating an explanatory theory of ‘Experienced Understanding’, which is composed of five major sub categories: Raising the Subject, Working the Problem, Making the Transition, Time/Timing – Getting it Right and A Good Death is Dying Well. It is proposed the outcomes of this research have the potential to inform current practice regarding end-of-life decision-making and care in critical care, including how nurse’s skills and experience can be utilised to facilitate both these processes. A significant reason for this potential is the nurse’s constant and consistent bedside presence. Consequently the nurse is the immediate health professional available to the patient and their family and acts as a conduit between these parties and the multidisciplinary team. To be effective, the skills required for this nursing population during challenging life events are diverse. The ability to empathise, by tapping into previous experiences of dealing with death, either professionally or personally, is important, along with understanding that care will not just include the patient but their wider family/whanau.