March 26, 2010 GUEST POST by Jason Bankert
It is the common belief that nurses are the care givers and thus are more compassionate than physicians who are often perceived as hard and emotionless. The Intensive Care Unit (ICU) can be emotionally draining as many patients are in critical condition or are terminal. The care of terminally ill patients is called end of life care or EOLC. How do health care professionals, such as physicians and nurses cope with the emotional burden of terminal illness in the ICU and how do there perception, treatment and communication involving terminal ill patients differ? These different perspectives impact physician-nurse collaboration as well as their satisfaction with the quality of EOLC (Hamric and Blackhall 2007).
In a recent study conducted in the ICUs of a rural hospital in Southwestern Virginia and an urban hospital in Eastern Virginia, investigators examined these questions to provide an insight on how these different perspectives on EOLC ultimately impacts patient care and what interventions can be taken to reduce moral distress and improve physician-nurse collaboration (Hamric and Blackhall 2007). The study, based on survey responses, showed that RNs experience more moral distress during EOLC than do physicians, even though both groups identify the situation as morally distressful (such as aggressive treatment as requested from a family member when both groups feel the treatment is unnecessary (Hamric and Blackhall 2007). As a result, these nurses are less content with their environment or the perception of the quality of care given to the terminal patient. This higher emotional burden on nurses may be the result of their job. It is the nurses who provide the majority of the bedside care during EOLC and are in contact with the patient more often than physicians. Also, nurses lack finally authority over the treatment options implemented by physicians. Even though nurses may disagree with the way physicians communicate prognosis and diagnosis, they feel that they have no say in the final decisions regarding patient treatment during EOLC.
The emotional environment is more important for nurses who are in contact with the patient more often than physicians, providing most of the daily beside care tasks (Hamric and Blackhall 2007). Therefore, it is necessary to improve this environment to ultimately improve the overall quality of patient care. The best care in the ICU occurs when nurses are active participants in diagnosis and treatment decisions and are active in communicating with patients and families alongside physicians (Hamric and Blackhall 2007). In order to provide a environment where nurses can be proactive in the patient care, special attention and policy needs to be implemented to increase physician awareness of the extra emotional burden experienced by nurses and respect their input in regards to EOLC. Equally important is the improvement of physician-nurse collaboration. This may be accomplished by promoting open communication about the different perspectives of EOLC through team meetings, individual meetings with chief staff members and conferences involving staff and specialists from other institutions.
Hamric, A. B., L.J. Blackhall. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Critical Care Medicine, 35, 422-429. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/17205001
I cannot imagine having to put on a happy face all the time for patients you know are not going t omake it through. Open communication and I beleive the tone of a nurses voice can ultimately sooth the patient making them more comfortable. At their stage, isn’t that all that matters? I wonder if these nurses have to take special courses to prepare themselves for depressed patients or patients with not the most optimistic outlooks. I think it is important that nurses understand because doctors are so busy they cannot give the patients the mental support they need. Communication between doctors and nurses needs to be on-point with terminally ill patients to apply the highest quality of care and support that patients need. I can see how this could put stress on a nurse. What if they have a bad day… they have to maintain a positive outlook for their patients. Nurses appear almost as important to the patient as the docotor is during their hospital stay.
As a nurse working in the Cardiac Intensive Care Unit for fifteen years, it has been my privilege to be involved with several EOLC patients. It is my perception that the stress is highest on first the patient, then the family of the patient (highest on the family if the patient is unaware of surroundings), and then the nursing staff. As was mentioned in the article, the nurse is at the bedside around the clock and as such deals with the follow through of decisions made with regard to the patient EOLC. In our facility, a private non-profit hospital, the ethicist, physicians involved with the patient, and the family made the decisions about EOLC. The nurse went to these meetings and had a clearly defined role as the liaison for the family; a purely supportive and somewhat interpretational position. The delivery of the individual plan of care agreed upon in those meetings with regard to the patient, was usually completed at the bedside by the nursing staff, with the family present, over what generally ended up being a number of days. I totally agree that open communication and candid dialogue is the precursor to improving physician-nurse collaboration and thus creating a higher quality of care during this transitional period from life to death.