Surrogate decision making for the critically ill intensive care unit patient

Abstract

The technological complexity of the ICU is often focused on saving lives however, it is frequently a place to support the dying. Because of the serious nature of critical illness, patients are unable to communicate their wishes, values and views. Family members are often called upon to communicate the critically ill patients’ wishes and many report feeling burdened with the task. The distress described may lead to difficulty mobilizing coping mechanisms and may affect their ability to make appropriate decisions for their family member’s care. Hence, an in depth understanding of the surrogate’s experience is critical to plan effective interventions and provide anticipatory guidance to support the process of making decisions around end of life care. Objective The purpose of the study is to describe the surrogate decision makers’ appraisals of the demands of decision making for a critically ill adult intensive care unit patient and the coping strategies employed by them during this experience. Method A descriptive study design using a qualitative interviewing approach extracted perceived stressors and coping strategies using systematic, focused thematic analysis guided by Folkman and Lazarus’ Stress and Coping Paradigm. Findings Respondents appraisals identified the following perceived stressors: doubt of self efficacy, unknowns, impingement of real life, and problematic relay of information. The surrogates’ perception of their ability to manage the decision making process required their awareness of the decision making role and magnitude of illness, their need to form partnerships, time to reflect on prior discussions and experience, and their appraisal of the patients’ suffering. Participants described emotion and problem based coping strategies they employed during the task. To emotionally justify their decisions, surrogates’ referred to their understanding of patient wishes and sought solace and comfort from the health care staff. In addition, surrogates used strategies to solve problems encountered including dealing with others, employing strategies to decrease their uncertainty and mobilizing time to process the events unfolding. Conclusions End of life decisions in the intensive care are complex and demanding. A better understanding of the process may guide health care professionals in developing focused interventions to assist surrogates through a painful process.