Strategies for the ICU Team
Undoubtedly, there will be patients in the ICU who will continue to wish for life-prolonging measures despite the health care team's education and recommendation to consider a more comfort-directed approach. Although this could be difficult to accept as a nurse, it could be used as an opportunity to get to know patients better and to explore what is driving that decision. Dr Timothy Quill explains that patients who say they want "everything" may or may not actually want those treatments that the physicians feel may be more harmful than beneficial. Quill recommends asking patients or families questions such as "what are your biggest fears?" He states that for many patients there is a fear that if they start to set limits to their treatment, the medical team will become "less vigilant" when changes in their health develop. They may have spiritual, psychological, or social stressors that are impairing their ability to cope with goals-of-care discussions. Other questions that may be helpful as nurses explore their patients' goals are to ask them to define treatment success and what are they willing to go through in order to achieve it. Be aware that they may not trust the health care system. If they are part of the population with known health care disparities or limited access to care, this is often the case. Nurses need to develop a trusting relationship with patients in order facilitate goals-of-care discussions. Reiterate to the patients that the medical team will never stop caring for them even when they cannot cure them and that there is always more that can be done to alleviate suffering. Because goals of care can and often do change over time as the disease progresses, nurses must maintain a therapeutic relationship with the patients and families in order to support them through those transitions.
As shown in this case, L.S. and his wife chose a course of treatment at the end of his life that most nurses and health care providers would disagree with. However, this treatment plan was offered to him, and he made an informed decision based on his goals for showing his children he had attempted everything possible to live longer. This case also demonstrates a loss of a therapeutic relationship between nurse and family.