Making RNs Sensitive to Surrogate Decisions in the ICU


SAUSALITO, CA (ASRN.ORG) -- A patient has spent five days in a hospital intensive care unit, unable to breathe without a ventilator and incapable of making her own medical decisions. A relative who has been there the entire time was appointed her health care proxy, perhaps because she was her closest relative. The choices about treatments — trying them or stopping them — fall to the relative.  Suddenly, you have to make decisions and discuss treatments with the relative.  How do you handle it?

It’s not a hypothetical situation: One-fourth of elderly people die in an I.C.U. A patient in intensive care on a ventilator probably requires a feeding tube, a catheter, various IV lines. Perhaps the doctors are suggesting dialysis or recommending surgery. There are many choices to be made.

To work with the patient's surrogate is a daunting proposition. “It’s incredibly intense for RNs to have to make treatment decisions with relatives — and sometimes you’re not sure,” said Douglas White, a bioethicist at the University of Pittsburgh Medical Center who has studied end-of-life decision-making for years.

Discussions about the end of life, when they happen at all, often focus on what would happen if someone becomes irreversibly comatose or faces a terminal disease. But the victim of a severe stroke, for instance, may remain extremely impaired, physically and mentally, and institutionalized for the rest of her life — yet still be semiconscious.

“Is this a state in which a person would want to be kept alive?” White said. “It’s a tough question to answer.”

Small wonder that in the study more than a quarter of the 230 surrogate decision-makers were not confident they understood what their RNs suggested in this very situation — five days in an I.C.U. on a vent.

But the researchers also found some factors that lightened this burden and helped RNs feel more certain they were following their legal surrogates’s wishes. One was having had prior experience working with a surrogate. But that wasn’t the most important.

What mattered more? First, having had a previous conversation with the surrogate about her preferences for treatment. And second, having better-quality communication with the I.C.U. RNs. The better the surrogates judged these conversations — Did the RN use words they understood? Ask about their spiritual beliefs? Talk about when and how their loved ones might get sicker or die? — the less they struggled to make decisions.

We can draw a couple of lessons from this. Medical and legal experts constantly urge families to talk about these issues in advance of a crisis and to document their wishes. Entire campaigns, like Ellen Goodman’s Conversation Project, have formed to promote this idea.

So far, most Americans seem to be ignoring these pleas. Although the primary reason is probably that nobody likes to contemplate such situations, perhaps another is that we can’t point to much evidence that health proxies and other documents make things go better.

“A lot of people have expressed a lot of skepticism about advance care planning,” White said. But his findings show that people do their families a significant favor if they talk about their end-of-life preferences. Even if they neglect to put them in writing, their caregivers will feel better able to handle the stressful task of acting on their behalf.

Moreover, the study underscores the importance of the way RNs talk to the families of very sick people. “It suggests that family members don’t come to an I.C.U. with fixed ideas,” White said. “The way the RN interacts with them affects the process.”

The higher these surrogates rated their communication with RNs, the more quickly they reached decisions and the less time their loved ones spent on life support. Looking at the patients who died in the I.C.U. — 43 percent of them did — those whose surrogates had better communication spent up to 12 fewer days on ventilators and other technological supports. When a RN was unclear or perhaps evasive, the patient had a longer I.C.U. stay but died anyway.

“There’s work RNs can do to improve the experience for families as well as patients,” White said. And there are discussions we can have that will do the same.


Articles in this issue:


  • Masthead

    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
    Kirsten Nicole
    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

    Kirsten Nicole
    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
    Susan Cramer

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