The practice of expert critical care nurses in situations of prognostic conflict at the end of life

The purpose of this qualitative study was to explore the phenomenon of poor patient prognosis and actions taken by expert critical care nurses when their perceptions of the usefulness of aggressive medical therapies differed from those of family members or physicians. In addition, an exploration of the reasons given for their actions was conducted. Twenty-one critical care nurses nominated as experts by a clinical nurse specialist or nurse educator were interviewed. The participants practiced in adult critical care units in one of three urban teaching medical centers, three urban private facilities, and one community hospital in Southwest Texas. The intent of the interviews was to elicit the nurses’ narratives, as narrative thought and understanding are essential to an elucidation of ethical knowledge and agency (Vitz, 1990) The interview questions generated both narrative and non-narrative data each of which required different analytic approaches. The narrative data were analyzed using techniques suggested by Riessman (1993, 2000) and Labov (1972, 1997). Identification of recurring narrative plots was accomplished using analytic strategies described by Polkinghorne (1995) and Ayres (2000). Thematic analysis (Coffey & Atkinson, 1996) was used to analyze the non-narrative responses. Analysis of the narrative exemplars yielded three recurrent plots while three main themes and thirteen subthemes emerged from the thematic analysis. The data revealed a compelling and diverse range of expert nurses’ experiences responding to patient situations of extreme vulnerability with actions to prevent further technological intrusion, honor patient and family wishes, and facilitate a good death. The ability to effectively advocate in these situations was enhanced by professional responsibility, maturity, communication skills, and having personal experience with dying and death. In contrast to previous research, the expert nurses in this study believed they exerted a powerful influence on the clinical and ethical components of patient care. The experience of expert critical care nurses in humanizing end of life care and shaping decision making processes around the event revealed opportunities for both improving and informing education and practice. Creating an ethical environment in the ICU will necessitate introduction of a new model that emphasizes collaborative decision making and integrates palliative care.