Discrepancies between Perceptions by
Physicians and Nursing Staff of Intensive
Care Unit End-of-Life Decisions
Edouard Ferrand, Francois Lemaire, Bernard Regnier, Khaldoun Kuteifan, Michel Badet, Pierre Asfar,
´ ´ ´
Samir Jaber, Jean-Luc Chagnon, Anne Renault, Rene Robert, Frederic Pochard, Christian Herve,
Christian Brun-Buisson, and Philippe Duvaldestin for the French RESSENTI Group
Reanimation Chirurgicale, Hopital Henri Mondor; Reanimation Medicale, Hopital Universitaire Henri Mondor, AP-HP, Creteil;
´ ˆ ´ ´ ˆ ´
´ ´ ˆ ´ ´ ˆ
Laboratoire d’Ethique Medicale et de Sante Publique, Hopital Necker Enfants-Malades; Reanimation Medicale, Hopital Universitaire
´ ´ ˆ ´ ´ ˆ
Bichat-Claude Bernard; Reanimation Medicale, Hopital Universitaire Cochin, AP-HP, Paris; Reanimation Medicale, Hopital La Source,
Orleans; Reanimation Medicale, Hopital Universitaire La Croix Rousse, Lyon; Reanimation Medicale, Centre Hospitalier Universitaire,
´ ´ ´ ˆ ´ ´
´ ˆ ´
Angers; Reanimation Chirurgicale, DAR B, Hopital Universitaire Saint-Eloi, Montpellier; Reanimation Polyvalente, Centre Hospitalier
´ ´ ´ ´ ˆ ´ ´
General, Valenciennes; Reanimation Medicale, Hopital Universitaire de la Cavale Blanche, Brest; and Reanimation Medicale,
Hopital Universitaire Jean Bernard, Poitiers, France
Several studies have pointed out ethical shortcomings in the deci- legitimate when there is disagreement among the caregivers
sion-making process for withholding or withdrawing life-support- (15). The considerable moral responsibility conferred on
ing treatments. We conducted a study to evaluate the perceptions nurses by their unique proximity to the patient and his/her
of all caregivers involved in this process in the intensive care unit. relatives and their interaction with the physician team are
A closed-ended questionnaire was completed by 3,156 nursing staff strong arguments in favor of including nurses in the speciﬁc
members and 521 physicians from 133 French intensive care units DFLST process (14, 16–19). Recently, two lawsuits in France
(participation rate, 42%). Decision-making processes were per- and one in Belgium have been ﬁled against ICU physicians
ceived as satisfactory by 73% of physicians and by only 33% of the
who had withdrawn mechanical ventilation from hopelessly
nursing staff. More than 90% of caregivers believed that decision-
ill patients (20–22). In these three instances, the lawsuits were
making should be collaborative, but 50% of physicians and only
27% of nursing staff members believed that the nursing staff was
ﬁled by nurses, who charged the physicians with euthanasia.
actually involved (p 0.001). Fear of litigation was a reason given by This indicates a major dissent among caregivers and great
physicians for modifying information given to competent patients, dissatisfaction of nurses about the handling of DFLSTs in the
families, and nursing staff. Perceptions by nursing staff may be a ICU. In one of the French cases, the physician was found guilty
reliable indicator of the quality of medical decision-making pro- in 1995 of homicide, a ruling that gave rise to considerable
cesses and may serve as a simple and effective tool for evaluating debate (20). The Belgian case is awaiting trial, but the Belgian
everyday practice. Recommendations and legislation may help to Society for Intensive Care has issued a position paper sup-
build consensus and avoid conflicts among caregivers at each step porting the physician, and a change to existing legislation on
of the decision-making process. DFLSTs is being considered by the Belgian parliament (22).
The absence in most European countries of recommenda-
Keywords: end-of-life decisions; ethics; decision-making; critical care; tions from scientiﬁc bodies and of legislation on DFLSTs in
critical care medicine probably contributes to the occurrence
Over the last few decades, decisions to forego life-sustaining of conﬂicts among ICU caregivers. In May 2002, the French
treatments (DFLSTs) have become common in intensive care ´ ´
Language Society of Critical Care Medicine (Societe de Re- ´
units (ICUs) (1–4). The guidelines or legal precedents that animation de Langue Francaise) issued its ﬁrst recommenda-
legitimate these decisions in some countries (5–8) are proba- tions on DFLSTs (23). We conducted a survey to evaluate the
bly used as a point of reference elsewhere (9, 10). Several perceptions of all caregivers in DFLSTs for ICU patients who
studies have pointed out ethical shortcomings in the decision- are mentally incompetent. In France, competent patients de-
making process, including failure to consider nurses’ opinions cide for themselves, but decisions for incompetent patients are
(4, 11). Whereas physicians are primarily concerned with left to the physicians, not the family members. Conﬂicts about
curing their patients, nurses focus on the impact of care on values and ambiguity in relationships among caregivers have
their patients (12–14). A major issue is whether consent of the been suggested (24) and may be ampliﬁed by the need to
patient or surrogate is sufﬁcient to make DFLSTs ethically make DFLSTs. Few studies have evaluated the hypothesis
that good collaboration, a major determinant of nurse satis-
faction, may improve the experience of dying patients. We
speciﬁcally sought to assess associations linking ICU policies,
decision-making processes, co-operation among nurses and
(Received in original form July 26, 2002; accepted in final form January 6, 2003)
physicians, and caregiver satisfaction, as reported by the nurs-
Supported by a grant from the Direction des Hopitaux (Programme Hospitalier
de Recherche Clinique AOM 98 301).
ing staff and physicians. This study conﬁrms that perceptions
of nurses and physicians differ widely.
Correspondence and requests for reprints should be addressed to Edouard
Ferrand, Service d’Anesthesie-Reanimation, Unite de Reanimation Chirurgicale et
´ ´ ´ ´
Traumatologique, Hopital Henri-Mondor, AP-HP, 51 rue du Mal de Lattre de Tas-
signy, 94010 Creteil cedex, France. E-mail: email@example.com
This article has an online supplement, which is accessible from this issue’s table
of contents online at www.atsjournals.org We sent a study project and reply form to the medical director and
Am J Respir Crit Care Med Vol 167. pp 1310–1315, 2003
senior head nurse of each ICU in the 320 university or general hospitals
Originally Published in Press as DOI: 10.1164/rccm.200207-752OC on January 24, 2003 on a list published by the French Language Society of Critical Care
Internet address: www.atsjournals.org Medicine. The reply form asked who would be the local investigator,
Ferrand, Lemaire, Regnier, et al.: Perception of End-of-Life Decisions 1311
how many physicians and other professionals worked in the ICU, their TABLE 1. CHARACTERISTICS OF THE NURSING STAFF
job title, and their work shift. In each ICU, all caregivers who had been MEMBERS INCLUDED IN THE STUDY
working in the ICU for at least three months were invited to participate
Characteristics n (%)
in the study. Physicians included residents, fellows, attending physicians,
and the ICU director. The nursing staff included nurses, nursing assis- Job title
tants, physiotherapists, and head nurses from both day and night shifts. Total 3,156
Physiotherapists approach patients in a manner similar to nurses, in terms Head nurses 158 (5.0)
of the nature of the care they provide and the attention they give to what Nurses 2,060 (65.3)
patients express; consequently, we included the few physiotherapist Nurse assistants 874 (27.7)
participants into the nursing staff category. Physiotherapists 64 (2.0)
Time in the ICU
Survey Instrument Total 3,156
1 yr 369 (11.7)
Each caregiver was asked to complete a 103-item physicians’ question- 2 yr 331 (10.5)
naire, or a 95-item nursing staff questionnaire in French (an English 2–5 yr 799 (25.3)
translation of both questionnaires are available in the online supple- 5 yr 1,657 (52.5)
ment). The eight additional items in the physicians’ questionnaire were Shift
about the operation of the ICU and concerns regarding litigation. There Total 3,156
were no other differences between the two questionnaires. All questions Day 1,269 (40.2)
were closed. Completion of the questionnaire required approximately Night 432 (13.7)
30 to 45 minutes. Day and night 1,455 (46.1)
For the pretest validation of the questionnaires, we conducted semi-
structured interviews with attending physicians, head nurses, nurses, Definition of abbreviation: ICU intensive care unit.
and nurse assistants on the staffs of the medical ICU in Poitiers, France
and the surgical ICU in Creteil, France. These interviews showed that
the questionnaires were easily understood and that the full range of
response options was used. Ethics Committee
Because the terms “withdrawing,” “withholding,” “ethical standards,”
and “high-quality decision-making” can be unclear or can give rise to a This study was approved by the Ethics Committee of the French Lan-
variety of interpretations, participants were provided with the following guage Society of Critical Care Medicine.
1. “Withdrawing life-support treatment” was deﬁned as discontinu-
ation of one or more treatments without replacement by an equiv- Univariate analyses were used to compare the variables of interest
alent treatment, with the objective of allowing a disease process between physicians and nursing staff. The 2 statistic was used to com-
to run its course and with the knowledge that this might lead to pare categoric variables. Categoric variables are expressed as percent-
the patient’s death. age of the group from the group from which they were derived, with
2. “Withholding life-support treatment” was deﬁned as a decision their 95% conﬁdence intervals.
not to use or not to intensify one or more treatments, with the Multiple logistic regression analysis was performed to examine the
objective of allowing a disease process to run its course and with relation between the characteristics of the caregivers and their percep-
the knowledge that this might lead to the patient’s death. tions of DFLSTs.
3. A “commitment of the ICU to high ethical standards” was deﬁned
as the existence of procedures aimed at ensuring compliance with RESULTS
ethical principles and legal obligations, as well as diffusion within
the caregiver team of speciﬁc information on patients, including Of the 320 ICUs canvassed for the study, 157 (49%) agreed to
religious beliefs, prior quality of life, expressed wish to receive participate. Of these 157, only the 133 units with more than
or not to receive resuscitation, family members and their wishes, 10% of the personnel returning completed questionnaires were
history of the disease, prognosis of the current disease, manage- included in the study.
ment strategy, and expected future quality of life.
4. “High-quality decision-making” was deﬁned as a process involv-
Of these 133 ICUs, 90 (67.7%) were mixed medical–surgical,
ing the following sequence: collection of the opinions and pro- 22 (16.5%) were surgical, and 21 (15.8%) were medical. Ninety-
posals of all those involved, whenever possible (patient, families, eight (73.6%) ICUs were in university hospitals and 35 (26.4%)
and all caregivers); sharing of decisions among the caregivers and in general hospitals. Questionnaires with answers to more than
family; sharing of decisions about which treatments should be 90% of the items were returned by 3,156 of the 6,341 (49.8%)
withdrawn or withheld; sharing of decisions regarding modalities nursing staff members (Table 1) and by 521 of the 915 (56.9%)
of foregoing life-sustaining treatments; and information of all physicians (Table 2) working in the 133 ICUs.
those affected by the decision. Ninety-one percent (n 2,875) of the 3,156 nursing staff
Questionnaire Administration members and 99% (n 517) of the 521 physicians had personal
experience with DFLSTs as part of their work in the ICU.
The physician and nursing staff questionnaires were sent to the ICU
Tables 3 and 4 show how caregivers perceived DFLSTs and the
medical director and senior head nurse, respectively. Both question-
naires were sent twice, 21 days apart, in June 2000. All ICUs whose place of these decisions in the ICU.
head physician and senior head nurse agreed to participate in the study
ICU Commitment to High Ethical Standards
were included and asked how many physicians or nursing staff members,
respectively, worked in their ICU. In each ICU, a physician or nursing Sixty-ﬁve percent of nursing staff members (n 2,036) and 78%
staff member was designated to hand out and collect the questionnaires. of physicians (n 415) believed that their ICU was committed
Between July and September 2000, each physician and each nursing to high ethical standards. Physicians were more likely than nurs-
staff member in the participating ICUs was given a questionnaire. ing staff members to believe that the nursing staff was involved
Completion of the self-administered questionnaire was voluntary. The
in this commitment (75% of physicians [n 396] vs. 43% of nurs-
cover letter explained that there were no codes that could be used to
link a completed questionnaire to a particular respondent. This state- ing staff members [n 1,360]; p 0.001) with no differences
ment was reinforced by a detailed pledge of anonymity from the investi- between ICUs of university and general hospitals (data not
gators, printed on the cover of the questionnaire. shown). Nursing staff members in surgical ICUs were more likely
Data collected from the questionnaires were double keyboarded. to believe that they were not sufﬁciently involved by physicians
1312 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 167 2003
TABLE 2. CHARACTERISTICS OF THE PHYSICIANS INCLUDED TABLE 4. CAREGIVERS’ PERCEPTIONS OF THE PLACE OF
IN THE STUDY DECISIONS TO FOREGO LIFE-SUSTAINING TREATMENT IN
THE INTENSIVE CARE UNIT
Characteristics n (%)
Nursing Staff Physicians
Job title Perceptions of DFLSTs in the ICU Care n (%) n (%)
ICU medical director 90 (17.2) Indispensable 2,563 (81) 417 (79)
Senior attending physician 9 (1.7) Made too rarely 951 (30) 125 (24)
Attending physician 186 (35.7) Made too often 33 (1) 12 (2)
Clinical fellow 40 (7.6) Useless 4 (0.1) 2 (0.4)
Part-time physician 75 (14.4) Dangerous 187 (6) 15 (3)
Residents 121 (23.2)
Time in the ICU Definition of abbreviations: DFLSTs decisions to forego life-sustaining treat-
Total 521 ment; ICU intensive care unit.
2 yr 149 (28.6)
2–10 yr 171 (32.8)
10 yr 201 (38.6)
Definition of abbreviation: ICU intensive care unit. Involvement in the decision-making process of a professional
who had no role in patient care was viewed favorably by 58%
of nursing staff members (n 1,830) and 42% of physicians
(n 221). Most nursing staff members favored a psychologist,
than were their counterparts in medical or medical–surgical whereas physicians’ responses were equally distributed among
ICUs (16.7, 20.1, and 31.1%, respectively; p 0.0001). the various possibilities suggested to them (Table 5).
Among physicians, 79% (n 418) believed that, before mak-
Satisfaction with the Process for Making Decisions to ing a DFLST, they considered the opinion of the nursing staff
Forego Life-Sustaining Treatment regarding the course of the patient’s treatment in the ICU, as
DFLST processes were believed to be always or usually satisfac- compared with only 31% of nursing staff members (n 953)
tory by 73% of physicians (n 386), as compared with only (p 0.001). Furthermore, 32.2% of physicians (n 170) and
33% of nursing staff members (n 1,033); this difference oc- 8.8% of nursing staff members (n 277; p 0.001) believed
curred both in university hospital ICUs (74.9 vs. 34.9%, p that DFLSTs were followed by adequate discussion of these
0.0001) and in general hospital ICUs (74.8 vs. 34.7%, p 0.0001). decisions. Also, 16% of physicians (n 85) and 21% of nursing
However, this perception differed according to the ICU category: staff members (n 647) reported that they felt isolated most
both physicians and nursing staff members were more likely to of the time.
be satisﬁed with decision-making processes in medical ICUs (82 Perceptions by Nursing Staff Members According to
and 43%, respectively) than in medical–surgical ICUs (75 and Work Shift and Time in the ICU
36%) or surgical ICUs (64 and 24%) (p 0.0001). For both
physicians and nursing staff, satisfaction with decision-making Night-shift nursing staff members had signiﬁcantly different per-
processes was signiﬁcantly associated with perception of a com- ceptions of the decision-making process than did their day-shift
mitment of the ICU to high ethical standards (p 0.0001), colleagues (Table 6). Among nursing staff members, time work-
involvement of nursing staff in this commitment (p 0.0001), ing in the ICU had a signiﬁcant inﬂuence on perception of a
regular meetings to discuss ethical issues even when no DFLSTs commitment to high ethical standards, perception of involve-
were being considered (p 0.0001), and presence of a psycholo- ment by physicians, satisfaction with DFLST procedures, and
gist on the ICU staff (p 0.0001). adequacy of information received about the patients.
Decision-Making Communication with the Family
The overwhelming majority of caregivers agreed on what should Presence of the nurses at meetings to discuss DFLSTs with
be done theoretically concerning collaborative decision-making the family was considered necessary by 56% of nursing staff
processes but strongly differed in their perceptions of actual prac- members (n 1,758) and 36% of physicians (n 189) (p
tice. A large majority of both nursing staff members and physi- 0.05). Seventy-ﬁve percent of nursing staff members (n 2,362)
cians (91 and 80%, respectively) stated that decisions should be and 75% of physicians (n 500) believed that the family should
collaborative, but only 27% of nurses and 50% of physicians be- always be informed of DFLSTs. However, only 42% (n 1,339)
lieved that this occurred in actual practice. and 66% (n 348), respectively, believed that families were
always informed in actual clinical practice (p 0.05). Only 69%
TABLE 3. CAREGIVERS’ DEFINITIONS OF DECISIONS TO
FOREGO LIFE-SUSTAINING TREATMENT TABLE 5. OPINIONS ABOUT HAVING A PROFESSIONAL NOT
INVOLVED IN PATIENT CARE PARTICIPATE IN DECISIONS
“Regarding the controversy about euthanasia, TO FOREGO LIFE-SUSTAINING TREATMENTS
do you feel the term “passive euthanasia” is
appropriate for designating treatment limitation Nursing Staff Physicians Would the process of making DFLST
decisions in the specific setting of the ICU?” n (%) n (%) benefit from participation of the
following professionals not Nursing Staff Physicians
No, the appropriate term is “refusal of futile care” 2,007 (64) 299 (57) involved in patient care? n (%) n (%)
No, the appropriate term is “palliative care” 304 (10) 76 (14)
Yes, the appropriate term is “passive euthanasia” 510 (16) 65 (12) Psychologist 1,295 (73) 113 (47)
No, the appropriate term is “active euthanasia” 54 (2) 40 (8) Physician 322 (18) 110 (46)
No opinion 102 (3) 27 (5) Ethics committee 764 (43) 97 (40)
Definition of abbreviation: ICU intensive care unit. Definition of abbreviation: DFLST decision to forego life-sustaining treatment.
Ferrand, Lemaire, Regnier, et al.: Perception of End-of-Life Decisions 1313
TABLE 6. DAY- AND NIGHT-SHIFT NURSING STAFF MEMBERS’ PERCEPTIONS OF THE
Nursing Staff Nursing Staff
n (%) n (%) p Value
Commitment of the ICU to high ethical standards 1,892 (60) 294 (68) 0.001
Feel they are not involved in the ICU’s commitment to ethics 431 (34) 138 (47) 0.008
Feel their opinions are not taken into account 228 (18) 259 (60) 0.0001
Feel they receive inadequate information about patients 230 (18) 328 (76) 0.0001
Satisfied with decision-making procedures 419 (33) 95 (22) 0.001
Definition of abbreviation: ICU intensive care unit.
of nursing staff members (n 2196) and 61% of physicians (n (Table 8), and concern about litigation was one of the reasons
323) (not signiﬁcant) believed that families should be informed given by physicians for modifying the information they provided
fully; the main reason for not providing full information was to competent patients.
that this might add to the family’s distress (35% of nursing staff Written DFLST procedures were available in only ﬁve ICUs.
[n 1,100] and 59% [n 311] of physicians). Thirty-three percent of physicians (n 175) believed that the
recent increase in litigation made written procedures desirable
Criteria for Decisions to Forego Life-Sustaining Treatments and 58% reported that their reports of DFLSTs in medical re-
Futility and no hope for future quality of life were the reasons cords did not faithfully describe reality (n 92, 17% of all
medical respondents). Fifty-seven percent of physicians (n
most often cited by nursing staff members and physicians for
301) were favorable to a change in current legislation about
initiating the DFLST process. Physical or psychological pain was
DFLSTs in the ICU.
cited by 29% of nursing staff members, as compared with only
5% of physicians (p 0.05). Few caregivers in either group cited
prior quality of life, economic cost, advanced patient age, or
family request (Table 7). These ﬁndings carry several messages. First, they indicate that
nursing staff members are often dissatisﬁed with the DFLST
Liability process in French ICUs. Second, we found marked differences
A total of 42% of nursing staff members (n 1,312) and 30% between perceptions of physicians and nursing staff members,
of physicians (n 159) believed that the nursing staff in charge with most physicians being satisﬁed with these procedures. Third,
of the patient should share with the physicians the responsibility fear of litigation clearly had an unfavorable inﬂuence on the
quality of DFLST procedures.
for DFLSTs, including legal responsibility. Twelve percent of
In this study, 75% of nursing staff members reported dissatis-
nursing staff members (n 391) believed that their role during
faction with DFLSTs. In this area of heated controversy on both
the discussion was only to make their opinion heard clearly,
sides of the Atlantic, the negative opinion of the caregivers who
without sharing in the responsibility for the decision.
are closest to dying patients is very disturbing, if not surprising.
Seventy-eight percent of physicians (n 411) but only 48% In a study conducted in ﬁve hospitals in the United States, 75%
of nursing staff members (n 1,526) believed that nurses (in of 759 nurses felt dissatisﬁed with management strategies and
the presence of the physician) could implement a DFLST made with their ICU’s commitment to ethical standards and 50% said
by the physician and consisting in increased sedation (p 0.05); that, when caring for dying patients, they performed acts that
corresponding ﬁgures were 76% (n 402) and 58% (n 1,846) contradicted their moral beliefs (25). Nurses who feel dissatisﬁed
for discontinuing vasoactive therapy (p 0.05), 63% (n 334) may perform acts that are not consonant with professional val-
and 51% (n 1,604) for decreasing the FiO2 (p 0.05), and ues. In a questionnaire study conducted by Asch, 17% of 1,139
30% (n 160) and 28% (n 898) for extubating the patient. nurses reported that they had engaged in euthanasia or assisted
Most physicians (76.7%, n 405) did not believe they were suicide, including 8% without an order from a physician (24).
breaking the law when they made DFLSTs. However, some Some nurses reported injecting saline instead of vasopressors
physicians reported that they worried about malpractice suits ordered by physicians. Nurse satisfaction is closely dependent
on the amount of collaboration within the caregiver staff (12,
26, 27). In our study, nearly 75% of nursing staff members be-
lieved that collaboration was inadequate during decision-mak-
TABLE 7. MAJOR CRITERIA USED TO MAKE DECISIONS TO ing, although the overwhelming majority of caregivers in both
FOREGO LIFE-SUSTAINING TREATMENT groups believed that collaboration was mandatory, as previously
Nursing Staff Physicians reported (28) or recommended (29, 30). This ﬁnding is in keeping
Major Criteria n (%) n (%) with the lack of involvement of the nursing staff in half the
DFLSTs recorded in the French national LATAREA study (4).
Futility 1,536 (43) 378 (72)
Emotional distress 343 (10) 13 (2)
Close interdisciplinary collaboration in the ICU is ethically
Physical suffering 567 (16) 16 (3) desirable and improves clinical outcomes (11, 12, 31–36). Differ-
Family request 52 (2) 2 (0.4) ences between predicted and observed mortality in ICU patients
Economic cost 4 (0.1) 0 (0) were signiﬁcantly associated with the degree of interaction among
No prior quality of life 186 (5) 34 (6) ICU staff members (31), and staff satisfaction with the decision-
No hope for future quality of life 796 (22) 71 (13)
making process was signiﬁcantly related to patient outcomes
Age 92 (3) 4 (0.8)
(32). In another study, the degree of physician–nurse collabora-
1314 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 167 2003
TABLE 8. PHYSICIANS’ CONCERNS ABOUT LITIGATION INDUCED BY DECISIONS TO FOREGO LIFE-SUSTAINING TREATMENT
“When you make a DFLST, do you worry that this might lead to litigation?” 123 (23.3)
“If yes, does your concern about litigation influence the amount of information you give to the patient?” 35 (6.7)
“If yes, does your concern about litigation influence the amount of information you give to the family?” 79 (15)
“If yes, does your concern about litigation influence the amount of information you give to the nursing staff?” 26 (4.9)
“If yes, does your concern about litigation influence the amount of information you record in the medical chart?” 92 (17.4)
Definition of abbreviation: DFLST decision to forego life-sustaining treatment.
Total n 521.
tion as perceived by the nurses was associated with patient out- legislation (40). Thus, the setting was very different from that
comes in a medical ICU but not in a surgical ICU or a medical– encountered in the U.S., where family members generally make
surgical ICU; collaboration as perceived by the physicians was DFLSTs for ICU patients, with the guidance and advice of physi-
not associated with outcomes (35). One of the limitations of cians (10, 41, 42). Conceivably, the lack of recommendations from
these studies is that only ICU death and a need for readmission ofﬁcial bodies like scientiﬁc societies and failure to acknowledge
to the ICU were evaluated: other outcomes such as patient/ the right of patients to full autonomy—from informed consent to
family satisfaction, cost, and longer-term mortality were not refusal of care—may lead to covert and consequently illegal prac-
considered (35). Furthermore, these studies excluded patients tices, to inadequate support of the patient and family, and to
for whom DFLSTs were made. Few studies have evaluated the insufﬁcient trust among ICU caregivers, a situation that may
hypothesis that good collaboration may improve the experience increase the likelihood of malpractice suits (20–22). Decisions
of dying patients. The observational phase of the SUPPORT made openly and discussed in depth with all those involved may
study published in 1995 showed a high rate of deﬁcient physician– be less likely to lead to litigation, rather than the opposite. The
patient communication and inappropriate treatment, with inade- recommendations on DFLSTs in ICUs published in May 2002
by the French Society of Critical Care Medicine (SRLF) strongly
quate pain management in dying patients and absence of knowl-
emphasize that physicians are under a legal obligation to docu-
edge of patient wishes regarding cardiopulmonary resuscitation
ment these decisions in the patient’s medical records (23).
in over 50% of cases (11). In the interventional phase of the
Some limitations of this study should be pointed out. First, the
SUPPORT study, a specially trained nurse interviewed patients questionnaire dealt with the physician and nurses’ perceptions as
and families about their preferences regarding end-of-life care to end-of-life care and was not intended to address the issue of
and encouraged caregivers to direct sufﬁcient attention to pain patients or family members opinions. Second, although we pre-
control (11). This intervention failed to improve outcomes re- tested our questionnaire, we acknowledge that a closed-ended
ﬂecting the experience of dying patients. The authors suggested questionnaire offers an assessment that is driven by those who
that the intervention may have occurred too late in the decision- write the response options, precluding new input from the re-
making process or that the physician–patient relationship might spondents. Third, although the response rate was similar to that
have been better had the patient spoken with the physician in many previous studies, the opinions of 75% of potential parti-
rather than with the research nurse (37). Furthermore, the nurse, cipants escaped evaluation by our study.
although specially trained, was not part of the ICU staff, raising Finally, the perceived poor quality of decision-making proce-
the possibility that a nurse from the ICU would perhaps have dures, together with the lack of an ofﬁcial statement from scien-
been more successful in improving communication among the tiﬁc bodies, suggests that nurses’ perceptions may play a role in
caregiver staff (38). preventing inappropriate decisions about patients whose consent
We found a signiﬁcant association between the degree of is not obtained (34, 43, 44). Physicians should initiate interdisci-
nursing staff involvement in the ICU’s general commitment to plinary collaboration by allowing all involved staff members
ethical standards and nursing staff satisfaction with DFLSTs, in to communicate their own opinions. DFLSTs generate painful
keeping with several earlier studies (34, 35, 39). In a 1996 single- conﬂicts between competing ethical values. Neither recommen-
center study among nurses who were involved in decisions to dations issued by learned societies nor changes in legislation can
withdraw mechanical ventilation and who believed the decision lighten the weight of the decision nor shift the responsibility
was morally correct, 84% were very satisﬁed with withdrawal away from the physician. However, recommendations, laws, and
procedures (33). good practices can help to build consensus and avoid disagree-
Another interesting ﬁnding from our study is that nursing ment among caregivers at each step of the decision-making pro-
staff satisfaction with DFLST procedures was signiﬁcantly better cess. Compatible with our study results, we suggest that operating
procedures should be developed to detect reservations, passive
in medical ICUs than in surgical ICUs, although a majority of
opposition, or resistance to decision-making processes, particu-
nursing staff members were very dissatisﬁed with these proce-
larly regarding DFLST, which require a high degree of collabora-
dures in medical, surgical, and medical–surgical ICUs. Baggs
tion and serenity. Measuring satisfaction of the various members
and coworkers made a similar observation and suggested that of the healthcare team with these decisions may be a simple and
the need for close collaboration may be greater in ICUs with more effective tool for evaluating everyday practice.
complex patients, such as those admitted to medical ICUs (35).
Finally, in our study, fear of litigation was probably an obsta- Acknowledgment : The authors are indebted to Dr. A. Wolfe for helpful advice
and thoughtful reading of this manuscript and to the hospitals and their staffs
cle to communication during DFLST process. About 50 and 20% for participating in the study.
of physicians reported that they gave inaccurate information to
families and to nursing staff members, respectively. At the time References
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