Whose death is it anyway? Withdrawal of life-sustaining treatment: An exploration of the experiences of intensive care nurses and doctors

Background: This study explores the experiences of intensive care nurses and doctors relating to the withdrawal of life-sustaining treatment (WLST) from imminently dying patients and considers the factors that affect decision-making and the process of WLST. Also considered are the perceptions of collaboration between nurses and doctors during the decision-making process, how WLST affects the two professional groups and their ethical perspectives in relation to WLST. Method: Narrative Inquiry was employed for this study; a purposive sample of intensive care nurses and doctors were invited to recount stories of their involvement in WLST. Of interest were experiences of ethical tension, experiences of collaboration, or lack of collaboration in decision-making concerning WLST. Data analysis: Participants’ stories were treated as data to derive themes that were reasonably consistent within or across stories. Initially, narrative analysis facilitated ‘restorying’; each narrative being co-constructed between researcher and participant. Applying McCormack’s lenses, further interpretive stories were written; followed by thematic analysis. Conclusions: In the facility where the study was conducted, doctors were emphatic that it was their decision to withdraw treatment, or there was shared decision-making with the family. However, concerns about traumatising the family and potential litigation could potentiate the continuation of treatment if family consensus could not be reached. This revealed that substitute decision-makers, supported by vague and ambiguous laws, may have contributed to protracting the dying process; potentially increasing patient suffering. The family became the ultimate decision-makers and the two entities that would be considered to support good end-of-life care, the law and the patient’s family, could be the two entities that form a barrier to it. The nurses perceived that the wishes of the family often took precedence over the best interests of the patient. The doctors wished to limit pointless suffering but when compelled to continue treatment, their approach changed; perceiving the maintenance of sedation negated the potential for suffering. However, the initial decision to consider WLST was made to limit suffering, when at that time, the patient was sedated. This could be viewed as a self-protective mechanism for doctors; the nurses had no such protective mechanism. Overall, collaboration in decision making was limited; disagreements about the goals of treatment could engender moral distress, leading to conflict between professional groups. The doctors believed that when they continued treatment for dying patients, it was either in the best interests of the patients or their families; portraying ethical perspectives affiliated to beneficence and therefore, utilitarianism. However, nurses considered that continuing, what they considered to be non-beneficial treatment, suffering, and thus, harm was inflicted on patients and their families by protracting the patients’ dying process; portraying ethical perspectives affiliated to nonmaleficence and therefore, deontology. These are powerful findings that add to the body of knowledge in this field of research. The major recommendations of the study are that policy reform is warranted, with medical experts being involved in policy development. Mass public education is key to ensure substitute decision-makers fully understand the implications of the decisions they make