Barriers to Effective End of Life Nursing Care in ICU

RUNNING HEAD: RESEARCH PROPOSAL
RESEARCH PROPOSAL
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Topic – Barriers to effective End of Life nursing care and critical decision making in
Intensive care setting
INTRODUCTION
BACKGROUND
End-of-life cases within acute care, ICU’s, have been seen to increase with increase in
Australian population and with progressive age. About 140,000 of Australians was reported
to die every year – fifty four percent of whom have died in acute care hospitals due to lack of
end-of-life decisions (Sinuff et al., 2015). This is applicable even to the decision-taking
process in ICU settings globally. While the advance care and informed care practices are
directed to a deteriorating condition, the End of life care by the nurses and doctors are
directed to a more patient centered palliative care approach. This decision making between a
biomedical approach and an end of life care comes across a lot of conflicts in ideas, motives
and decision making amongst the doctors, nurses and between the nurses and doctors.
Consequently the end-of-life care and decision making are of paramount important
particularly in intensive care units where the patients are fragile, suffering from different co-
morbidities. With the advances in recent medical technology, intensive care units have the
ability to treat the patients who are in dire critical state and who previously had no chances of
surviving even in ICUs. When the patients are treated to make them survive, nurses and
doctors face an ethical dilemma (Thomas, Lobo & Detering, 2017) of the death that comes
with withdrawal of the life support systems (Curtis, 2016). It is often thought that Intensive
care unit nurses and the doctors have the expertise to care for EOL patients in a functional
way. However the poor communication (Walczak et al. 2017), ambiguity of medical (van der
Steen wt al., 2016), nursing roles, and deficient perceptions (Montgomery, Sawin &
Hendricks-Ferguson, 2017) of end-of-life decisions, are the key factors that prevent a proper
end-of-life care planning. The End of life care is about withdrawal of life prolonging systems

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that alleviates pain and discomfort and is replaced by a patient centered humanistic care with
life shortening possibilities.
These end of life decisions asks for a responsibility from the families, intensive care
staffs and decisions are taken without patient’s input which is again an ethical dilemma. This
might place a significant emotional burden on the patient and that is why end of life decisions
are often associated with stress. Despite clinical experience and knowledge, there is a fear of
abandoning the patient’s hope prematurely that frequently cite inadequate perception
(Wessman, Sona & Schallom, 2017) preparation and decision regarding end of life decisions.
Empirical data and information about the end-of-life care planning is missing. With
increasing incidents of EOL decision making, an understanding ICU nurses experiences is
needed. Insights to nursing experiences can be beneficial to an informed practice. It is also
pivotal to the development of an educational resource with the elevation of clinical standards
regarding end-of-life care.
RESEARCH PROBLEM
Issues involving end-of-life decision making have been a great barrier to EOL and
palliative care. The nurses have described their personal feelings like stress (Katz & Johnson,
2016), anger, frustration sadness, moral distress and helplessness. This moral distress and
cognitive drawback is often associated with nurses being unable to influence the EOL
decisions and the more precisely, the decision-making processes. EOL care replaces the
aggressive care that is not benefiting for them. Aggressive care (Wright et al., 2016) leads to
conflicts with patients and their families’ but they are often indecisive about the treatment
termination. Moral distress (Dzeng et al., 2016) has been reported to be associated with ICU
nurses’ ineffectiveness to decide between life prolonging or life shortening treatments. Moral
distress has been seen a serious barrier in Intensive care unit nursing and especially to end of

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life care decisions. Such distress can cause severe burnouts, role dissatisfaction and disruptive
workplace behaviors. Critical care (Urden et al., 2019) and ICU nurses have often reported
that their moral distress has led to job dissatisfaction, psychological issues and they also
reported that EOL decision making and caring for a dying patient in a humanistic way have
made them more spiritual as a person.
Investigators those who explored the perceptions of nurses working in critical care
about end-of-life decision making, communication with patients, their families - has found
out that the treatment of physical symptoms and signs of the patient is dependent on
systematic and attentive processes along with provision of psychological guidance to patients
and even patient’s families. Important psychological support services is pertinent to the
ongoing EOL support, bereavement care of patient’s families. Easing the patients’ families in
critical situations is an important enabler to EOL nursing care. The critical care and the ICU
nurses need guidance from senior and experienced nurses while communicating with
patients’ families in hard stressful times. Special training programs in crisis and grieving,
bereavement management is imperative to spiritual (Bassett, Bingley & Brearley, 2017),
pastoral (Burgio et al., 2016) and psychological care (Chan, Webster & Bowers, 2016).
Various aspects of these critical care nursing and clinical environments has acted like barriers
to end-of-life clinical care. The conflicts and disagreements between doctors and nurses about
end-of-life decision making, physicians’ disregard for patients’ autonomy (Rodríguez-Prat et
al., 2016) avoiding the patient families, providing false hopes, providing ineffective pain
treatments and aggressive treatments. Factors that affect end-of-life quality care (Dillworth et
al., 2016) is the communication barrier between doctors and nurses. Hospital hierarchy plays
a vital role in physicians’ not collaborating with the nurses for an interventional care or EOL
care. Intensive care units are designed for treating these acutely diseased patients and not for
the dying patients and hence, ICUs have a completely different focus that make quality EOL