A Qualitative Look at End-of-Life Care in the ICU*
For example, quantitative research can identify for us the patients with the greatest statistical chance for success from a treatment, but it cannot create understanding from a crumpled Physician Orders for Life-Sustaining Treatment form pulled from a forgotten drawer in the dead of night or help us explore the best decisions about end-of-life care based on the words “unless it is survivable” or “only if reversible” scrawled in the margin. It is often these scenarios, intensified by prognostic uncertainty and muddled by potentially competing roles and interests (patients, families, physicians, nurses) (4, 5), that give rise to tensions between caregivers in the ICU. The complexities of these relationships, and emotions that arise from them, are explored in the accompanying study in this issue of Critical Care Medicine by Laurent et al (6).
Using in-depth interviews of staff members in two ICUs in an academic medical center, Laurent et al (6) explore the emotional experiences of nurses and physicians around decisions about end-of-life care and how their experiences influence those decisions. As the participants were asked to reflect on past difficult decisions in the ICU, the nurses reported feeling abandoned and not involved in the decision-making process. Emphasizing their close relationship with the patient, nurses felt torn between caring and advocating for the incapacitated patient and carrying out physician’s orders that seemed to them to increase or prolong the patient’s suffering. The physicians on the other hand identified primarily with the patient’s family and considered this partnership as the cornerstone of their decision-making process. Feeling ultimately accountable for the decisions made and therefore the patient’s outcome, the physicians felt conflicted about their responsibilities toward the family, the patient, and the medical team.
At first glance, it is easy to endorse the authors’ conclusions as they resonate with some of our own experiences and identify important sources of moral distress. Further appraisal of the research design and execution is necessary as we consider how to apply these findings to our own critical care experiences. As with quantitative research, qualitative research is only valid (or “trustworthy,” the preferred term in qualitative research) if the methods used are rigorous and transparent, the analysis appropriate, and the interpretation coherent (1, 2, 7). In this article (6), the authors’ use of interpretative phenomenological analysis (8) allows for in-depth exploration of each participant’s feelings but obtains that depth of expression at the expense of capturing a wider breadth of experience and accepting the constraints of a small, nonrepresentative sample (in this case, 10 physicians and 10 nurses). The choice of this small sample size is deliberate, as it is not meant to accurately measure the size or frequency of a problem, but to better understand the problem in depth.