Grigg,Robin
Critical Care Nurses’ Stories of EOL Care Obstacles
Renea, Beckstrand, College of Nursing
Introduction
The purpose of this project was to discover critical care nurses’ perspectives of
obstacles in providing end-of-life (EOL) care to patients. Because 20% of Americans
die in an Intensive Care Unit (ICU) (CDC, 2011), EOL care is a vital component of
critical care nursing. Therefore, discerning and overcoming obstacles to EOL care is
necessary in order for critical care nurses to provide quality EOL care. Additionally, The
National Institute of Nursing Research’s strategic plan lists five areas of focus, the third
being EOL care, emphasizing the need for EOL care research (NINR, 2014).
Methodology
A survey, containing quantitative and qualitative components, was mailed, after
receiving BYU IRB approval, to a random sample of 2100 critical care nurses across the
country. After the first mailing, an inadequate number of surveys were received,
prompting postcard reminders, and then a second mailing. Quantitative survey
responses were inputted into SPSS, a statistical analysis program, while qualitative
survey responses were recorded into Word documents. Specifically, I focused on
responses to the question: “Please share an experience you have had caring for a dying
patient that typifies the obstacles ICU nurses see in end-of-life care.” Once these
responses were recorded, responses were then divided into two categories: a narrative
story response and responses not containing a narrative story. To qualify as a narrative
story, responses needed to be in chronological format. Narrative stories were analyzed,
coded, and organized into themes.
Results
After the second mailing, approximately 600 surveys were completed by critical care
nurses. Out of the approximately 600 completed surveys 171 critical care nurses
answered the question: “Please share an experience you have had caring for a dying
patient that typifies the obstacles ICU nurses see in end-of-life care.” However, 73 of the
171 responses were narrative stories, thus only those 73 responses were analyzed for
themes, enabling identification of obstacles to EOL care. Three common themes were
found in theses narratives: overriding patients’ Do-Not-Resuscitate code status,
providing futile care, and giving false hope to patients’ families regarding patient
diagnosis and outcomes.
Currently, these narrative stories are being reviewed for further analysis. Additionally,
statisticians are analyzing quantitative survey data to obtain results. Several nursing
students, who also received ORCA grants, are coding the other qualitative survey
responses.
Discussion
EOL care has two major goals: maintenance of a dying individuals’ comfort, choices,
and quality of life and caring for psychosocial and spiritual needs of patients and family
(Attia, Elaziz, & Kandeel, 2012). Because the three major themes found in these
narrative stories from critical care nurses – overriding patients’ DNR status, giving false
hope to patients’ families, and providing futile care – violate the main goals of EOL care,
these themes are major obstacles to EOL care.
Overriding patients’ DNR status, whether by doctors or family members, is a violation of
dying individuals’ autonomy – or right to choice –, thus halting the first EOL care goal.
Moreover, quality EOL care includes nurses advocating for dying patients because at
EOL patients often loose physical ability to advocate for themselves. When family
members and doctors override patients’ DNR status, nurses loose ability to advocate,
impeding quality EOL care.
Another prominent theme found in these narrative stories was doctors giving false hope
to patients’ families. This obstacle was best seen in this example, following a narrative
regarding a patient’s hospital stay, a critical care nurse recounted
“Patient died. A family member said ‘No one told us he could die from this. If they
would have been honest with us, and told us he was going to die, we would’ve
gone home, had a barbecue, drank a beer, and let him die at home with his
family.’ “
In this example, giving false hope is another violation of the first goal of EOL. As seen
in the above example, when doctors are not forthright with patients and family members
regarding patient prognosis, patients and family members loose autonomy during EOL.
Additionally giving false hope, does not allow critical care nurses to provide for patients’
and family members’ psychosocial and spiritual needs, the second goal of EOL.
Furthermore, when nurses provide futile care to dying individuals, nurses mask
psychosocial and spiritual needs of patients and family members. Offering futile care
does not facilitate grieving or coping, two psychosocial needs of family members during
EOL care.
Conclusion
Because of the complex nature of EOL care, critical care nurses face many obstacles in
providing EOL care for patients. Identification of these obstacles can facilitate
implementation of quality EOL care for patients and families, meeting EOL care goals.
Through qualitative research, three major obstacles to EOL care were found.
Furthermore, additional research needs to be conducted regarding implementations to
overcome EOL care obstacles.
Attia, A., Abd-Elaziz, W. & Kandeel, N. (2012). Critical care nurses’ perception of barriers and supportive behaviors in
end-of-life care. American Journal of Hospice & Palliative Medicine, 30(3), 297-304.
Centers for Disease Control. (February 2011). Health United States, 2010: With special feature on death and dying.
Retrieved from http://www.cdc.gov/nchs/data/hus/hus10.pdf
National Institute of Nursing Research (2014). Implementing NINR’s strategic plan: Key themes. Retrieved from
https://www.ninr.nih.gov/aboutninr/keythemes#.VimTgbt0w6Y