Conflicts in Goals of Care at the End of Life

Abstract and Introduction

Abstract

Recent medical literature reports increased utilization of the intensive care unit (ICU) at the end of life, even for patients who are considered terminally ill, and the overall ICU adult mortality rate ranges from 10% to 29%. Therefore, ICU nurses require a level of comfort in caring for patients and families at this vulnerable time. At times, ongoing aggressive life-prolonging interventions for a terminally ill patient can create ethical conflicts and moral distress for nurses. This leads to the question: Can this level of treatment be compatible with a "good death?"Medical recommendations are made based on the patient's goals of care, appropriate treatment options, and associated benefits and burdens. How then should nurses respond when a patient or family does not agree with these medical recommendations? Through a case study, this article explores the moral and ethical conflicts that often occur in the ICU setting at end of life and aid to empower the ICU nurse to care for patients in a way that honors the patient's wishes and maintains a healthy nurse-patient relationship.

Introduction

The intensive care unit (ICU) is a site of care that can create great uncertainty for patients with a poor or terminal prognosis and their families. The usual culture of an ICU is one of restoring homeostasis with rapid responses and aggressive measures to help patients recover. But when a patient presents with what will likely be a terminal situation regardless of medical intervention, many providers want to support the patient and family into accepting a peaceful end-of-life experience and foregoing life-prolonging treatments. This can lead to ethical conflicts when clinicians and patients/families do not agree on the appropriate course of care. A case study will be used to explore the nebulous and personal definition of a "good death" and how clinicians can be confident knowing they provided the very best patient care at the end of life within an ethical framework.

L.S., a 38-year-old man with stage IV colorectal cancer was admitted to the ICU with dehydration and acute renal failure following a fourth cycle of salvage chemotherapy. He had previously been treated with surgical resection at the time of diagnosis 3 years prior, radiation therapy, and multiple courses of chemotherapy. Over the past 36 hours, however, he had become acutely ill with anorexia, nausea and vomiting, and altered mental status with a creatinine of 3.8 mg/mL. He requires vasopressor support, intravenous antibiotics, and bilevel positive airway pressure support. His oncologist reports in his admission note that L.S. had not tolerated the salvage therapy well, his performance status had been worsening (Eastern Cooperative Oncology Group performance status 3), and he had lost 25 lb over the past 3 months. L.S. is obtunded now and without obvious distress or discomfort. He has a wife, 3 young children under 12 years, who were all in attendance with their community pastor at the time of admission and made it clear they wanted "everything done to save him."
Twenty-four hours after admission to the ICU, L.S. continues to decline. He attempts to wake up and communicate with his family, but he is very lethargic and agitated. He is hemodynamically unstable and requiring blood transfusions. During multidisciplinary rounds, the primary ICU nurse requests a palliative care consult to help support the family and "make them understand L.S. is dying." A family meeting is held with all family and their pastor to review the current status, a poor prognosis for survival, and recommendations to shift to comfort-directed care. It has been determined that none of L.S.'s conditions are reversible, and his decline is due to the progression of his terminal cancer. His wife wants to keep L.S. a full code blue and reports L.S. told her to always "do everything you can to keep me alive for my kids." She shares that L.S. has been told by his oncologist that he is terminally ill, and the oncologist has recommended hospice to him several times, but L.S. has refused. He has told his family he wants to "go down kicking," and she feels it is his way of showing his family he did all he could to live for them. She feels obligated to honor his wishes.
After 5 days in the ICU, L.S. continues to decline overall. He is now less responsive, requiring increasing vasopressor support, and has been intubated. He is having frequent cardiac arrhythmias. The staff is growing resentful of the wife for not agreeing to shift his goals of treatment to comfort despite the medical team's advice. In fact, most of the staff request to not be assigned to him because they feel they are inflicting harm to him. During the night shift of day 5, L.S. goes into cardiac arrest, prompting a code blue to be called. Four rounds of advanced cardiac life support are provided, and he does not respond. The chaplain and charge nurse are with the wife and children to keep them updated and supported. The attending physician comes to tell her he wishes to cease attempts at resuscitation because L.S. is not responding to the treatment, and the wife agrees. L.S. goes into asystole almost immediately after the cardiopulmonary resuscitation (CPR) attempts are stopped.
After L.S. is pronounced, the family is appropriately grieving, but the wife states to the nurse she feels comfortable that she followed his wishes and "gave him every chance to live." The next morning at shift change, the nurses discuss the events of his arrest and case. Many staff are angry that "she put him through that." There is a great deal of sadness and frustration expressed by all of the staff surrounding the case.
Because of the dissention among staff, the nurse manager schedules a debriefing the following morning for the staff. A facilitator from the hospital's Employee Assistance Program and the unit chaplain lead the discussion to allow the staff to verbalize their feelings and emotions. By the conclusion of the session, everyone felt they at least understood the choices of the patient and family even if they did not personally agree with them. All agreed that they wanted more education and support surrounding difficult cases and ways to help themselves cope with providing care at the end of life.

According to the nursing and medical literature, most patients with advanced illness state they would want to die at home in the presence of family and with a focus on their comfort; however, only 25% of those patients will die at home, 25% in a nursing home, and the remainder will die in an acute care setting.^[1,2] More specifically, more than one-third of patients with advanced cancer in the United States spend their final days in the ICU receiving life-prolonging measures including ventilator support, artificial nutrition, and CPR.^[3] Less than 50% of these patients with cancer will receive hospice services, and most that do receive services for only a matter of days.^[1,4] There are many factors influencing these statistics including the patient's age, social situation, religious beliefs, and if he/she has had conversations about his/her end-of-life preferences and wishes.

It is reported that up to one-fifth of patients with metastatic cancer receive chemotherapy in the last 14 days of life.^[1,5,6] With rising health care costs, this trend is receiving more attention, and efforts are being made to decrease this rate when there is no documented benefit for the patient. Oncologists are often criticized for continuing this aggressive treatment when the patient is nearing the end of his/her life, but many times this is a patient choice and desire to "fight to the end."^[5]

When the patients and/or the medical specialists want to continue all efforts to prolong life, even in a terminal situation, many conflicts can arise within and for the ICU team. End-of-life care and the continuation (or discontinuation) of aggressive measures have been cited as 2 of the most prevalent conflicts in the ICU that lead to staff burnout and poor quality of care. Intensive care unit nurses specifically are faced with a challenge of maintaining treatment delivery and providing honest communication and emotional support to the family.^[7] This can lead to an internal struggle for the nurse who may be feeling he/she is hurting versus helping the patient. This type of conflict can lead to feelings of powerlessness and will ultimately lead to less than optimal health care delivery.^[8,9] The term "moral distress" has been used to describe this human response, and it has been shown to lead to staff burnout, high staff turnover, and compromised patient care.^[10] Conflicts and distrust between nurse and physician can also arise if there is a feeling that the patient and family have not been fully and accurately informed of the terminal prognosis and perhaps have been given false hope. When this occurs, nurses may feel the patient and family are not making informed choices about their goals of treatment when they choose to seek end-of-life care in an ICU versus choosing a more peaceful setting for their care.^[5]