Constructing the story: How nurses work with families regarding withdrawal of aggressive treatment in ICU - A narrative study

Background: Specific communication practices used by experienced intensive care nurses who are comfortable working with dying patients and their families in ICU to reach consensus on withdrawal of aggressive treatment and shift to palliative care are lacking in the literature. However, there are seven international qualitative studies relevant to this research. Important themes related to communication were composed of four elements: general communication and relationship building, recognizing the need to transition to palliative care, facilitating palliative care, and providing dignified care through to death. Aim: To describe the specific communication practices experienced intensive care nurses' comfortable working with dying patients' use with families to negotiate consensus on withdrawal of aggressive treatment and/or shift to palliative are at end of life. Design: A qualitative narrative study. Method: Purposeful sampling was used to recruit nineteen experienced intensive care nurses. A narrative approach was used for data collection and analysis. Results: Consistent with narrative inquiry the results describe an overall plot: "constructing the story" and five subplots that identify and describe communicative actions relevant to the plot. The five subplots are: (A) organizing and interpreting knowledge of different kinds from different sources; (B) learning who the patient is as a person and putting the medical diagnosis into the biographical life of the patient; (C) helping families see the deteriorating status of the patient; (D) imagining and acting on moral possibilities for end of life care; and (E) facilitating saying goodbye - the end of the story. Conclusion: Findings from this study enrich the understanding of how experienced nurses who are comfortable with dying patients communicate with families as they navigate the difficult path of transitioning from aggressive care to palliative care for their significant other in the intensive care unit. This research provides a beginning language that can enable caregivers to talk about and reflect on the complex communication necessary for good end of life care. The findings of this study have major implications for clinical practice and interdisciplinary education.