End of life – The nurses’ perspective

Intensive Care Unit (ICU) support is provided with the aim of maintaining the vital functions, reducing mortality and morbidity in patients with a severe critical illness.(1) Despite having newly developed technologies and improvement in care, the death rate in the intensive care unit remains high, ranging between 20-35%.(1) The care that people receive at the end of their lives has a profound impact not only upon them but also upon their families and carers. End of life (EOL) in the ICU is a challenge. Nature and spirituality have been superseded by all that medical science has to offer by way of technology and life support, prolonging the dying process and dictating the time of death.(2) Death as it occurs in the ICU is neither simple nor natural. Caring for dying patients and their families is thought to be most stressful and painful to the nurses who constantly attend to the patients whereas other healthcare providers can visit and then walk away.(3) There are only limited studies from the perspective of critical care nurses on obstacles and/or supportive behaviors that either restrict or promote good care for dying patients even though there are adequate documentation of the difficulties and inadequacies of providing EOL care to patients.(3) It is well identified that the nurses have a decision making role as they act as a link between families and physicians in decisions at the end of life while interpreting and explaining information.(2) It has been noted that the nursing paradigm of enhancing communication, reducing symptom burden, and supporting families are aligned with the common domains of EOL care.(4) The study using the grounded theory approach to formulate a conceptual framework of the nursing role in EOL decision making in an ICU setting concluded that the core concept, supporting the journey, became evident in four major themes: Being There, A Voice to Speak Up, Enable Coming to Terms, and Helping to Let Go. Nurses describe being present with patients and families to validate feelings and give emotional support, nursing work, while bridging the journey between life and death, imparting strength and resilience and helping overcome barriers to ensure that patients receive holistic care. The conceptual framework challenges nurses to be present with patients and families at the end of life, clarify and interpret information, and help families come to terms with end-of-life decisions and release their loved ones.(2) Thus involving the nurses in the multidisciplinary decision making of EOL care will be beneficial. Nurses play a very important role in EOL care by providing family care and collaborating with the rest of the medical team.(5) Working as a nurse within the wider ICU team requires good collaborative and communication skills and few studies have focused on how we foster these skills to enhance EOL care in the ICU. Little is known about the role of nurses in end of life in the critical care setting, and therefore a grounded theory study in this area is needed to further understand this important role.(2)