Intensive care nurses' attitudes to withdrawal of treatment

Introduction

Withdrawal of active treatment (WoT) is increasingly important as the mode of dying for patients treated in intensive care units (ICUs). The objective of this study was to ascertain whether ICU nurses feel adequately prepared to meet the challenges this presents.

Method

The study was performed in the 30-bed general adult ICU of an academic medical centre, using a self-administered, cross-sectional survey, comprising mainly closed questions and Likert scale responses to set statements, allowing numeric values to be assigned and an overall 'confidence score' to be calculated. Content and face validity of the tool were appraised through a pilot study. The following key factors were addressed: nurses' previous education regarding WoT, how beneficial they believed this to have been, their previous experiences of WoT, their confidence in their ability to communicate within the multidisciplinary team (MDT) and with relatives, their knowledge of the legal issues raised during WoT, and their priorities for strategies to improve the WoT process.

Results

One hundred and twenty-seven nurses were surveyed and 94 (74%) responded, of whom 91 (97%) had experienced withdrawal of treatment (WoT). The mean overall confidence score was 2.78 ± 0.5, but this was significantly higher (i.e. more confident) by nursing grade, previous experience and previous education (P < 0.0005 for all). Sixty-two per cent of nurses felt able to represent their own views and 81% the patient and/or family's views within the MDT, while 64% felt confident communicating with the family. Forty-three per cent of nurses had received some form of education addressing WoT, but only 55% felt it had benefited their practice. Fifty per cent were unsure of the legal issues surrounding WoT, and 72% felt unclear of the correct process for WoT. The three strategies felt most likely to improve WoT were written guidelines (74%), full supervision of first experience of WoT (79%) and a rostered study day (86%).

Conclusion

This survey shows that ICU nurses are uncertain about their own abilities and the process when addressing WoT. It confirms that both experience and education increase confidence and perceived knowledge, but suggests that education should be more effective. A more structured approach to WoT may also be of benefit.