Caregiver Experience in Critical Care Regarding Treatment Limits and Withdrawal

Background and Goal of Study
Ongoing organ support for dying patients may not be in their best interest and has resource implications. The decision to limit or withdraw active treatment in patients admitted to the intensive care unit (ICU) is often complex, multi-factorial, and emotive (1).  We aim to evaluate the ICU multi-disciplinary team (MDT) experience of managing patients with treatment limitation and identify areas needing improvement in order to enhance patient care, family experience and MDT efficacy.

Materials and Methods
ICU MDT members completed an anonymous questionnaire over a two-week period, detailing their personal experiences managing end of life patients. Closed and open questions were used and responses were analysed with quantitative and qualitative methods.

Results and Discussion
In total 40 responses were obtained.  All staff felt that decisions regarding treatment limits and withdrawal were not always effectively communicated to themselves, with 20 (69%) of junior staff and 3 (38%) of senior staff stating that communication within the MDT was ‘below ideal’
 
Thematic analysis identified several issues. These included the sole use of verbal communication, unclear written documentation, a lack of specific guidance and lack of consistency with frequent rotation of medical staff.  As instructions were not clear, junior staff, not confident with decision-making, would err on the side of caution, sometimes continuing inappropriate treatments.
 
Respondents described times where they felt miscommunication had limited the support they could offer patients and their families. They reported feeling upset, frustrated and embarrassed due to lack of information.  This led to a feeling that they were behaving in an unprofessional manner and were not providing the standard of care they desired. Staff felt that improved documentation clarifying any treatment limitations is needed to improve MDT communication and patient care.  

Conclusions
End of life care is vital for patients and their families.  In our study, staff members managing these situations felt that communication was sub-standard and this led to sub-standard care and personal and professional difficulties.  A proforma to clarify these decisions and improve MDT communication is being introduced to address these issues.  

References
1.  Wilkinson DJC and Savulescu J “Knowing When to Stop: Futility in the Intensive Care Unit”. Current Opinion In Anaesthesiology (2011). 24(2) p160–165.

Caregiver experience in critical care regarding treatment limits and withdrawal