Do the ICU Nurses Experiences Help in Evolving Medical Futility Guidelines - Research Paper Example

MEDICAL FUTILITY - Objective: - The objective of this review is to arrive at an answer to the research question, "Do the ICU nurses' experiences help in evolving medical futility guidelines" The first aim was to determine the experiences of nursing community in various fields and secondly the relation between the concept of medical futility and their perception of medical futility. Design: - Twenty nursing and medical journals in connection with nurses' experiences in ICU and medical futility were examined. Results: - Three main views were extracted from the review; they are: 1. Experiences of nursing community in various fields. 2. Nurses' perception of medical futility. And 3. Role of nurses in decision making. Search strategy: - Databases Blackwell Synergy, Entrez Pubmed, Cinahl, Nejm, and eMJA were searched using search terms, 'medical futility', 'nursing experiences', 'ICU experiences' and 'role of nurses'. Findings: - when the contents of literature are viewed through the glasses of the three extracted views, it is found that experiences of nurses form a great volume of data base. Nurse's perception of medical futility is not given due place in decision making by physicians. Conclusion: - Experiences of nurses in ICU are significantly helpful in decision making and evolving medical futility guidelines. INTRODUCTION: Terming the utility behind the medical system and its care oriented activities, as futility is an oxymoron. Treatments that do not fetch results/goals are considered as medical futility. If this can be taken as a rule, then any stage of treatment towards the curative goal can also be rejected as medical futility, because the stages of treatment may not land immediately on the anticipated results. The interactive gap between doctors and patients or their families worsens the situations in many decision-making junctures. Critical situations like withdrawal of life supporting systems and stoppage of ineffective medical interventions are to be managed in consensus with the patients and families. To achieve this consensus more than five sittings of negotiations are needed at times. Lack of skill in manoeuvring the negotiations in the interest of patients on the part of doctors and physicians of entry-level forms the crux of the problem. The term futility is associated with the target-missed. When maintaining the quality of life of the patient is the target, the medical futility makes no sense. Only when life saving is the issue, medical futility works; that too because of the occurrence of death, which is never in the hands of us. Thus keeping a negative target-- that is death-- as a measure to judge the medical interventions seems quite irrelevant. During the last decade of 20th Century, medical futility guidelines began to emerge at different levels in many institutions. The role of nursing community in ICU and their perception of medical futility were unfortunately given less importance in evolving the guidelines. The nursing community by virtue of their proximity normally conceives the psychosocial aspects vividly with the patients and their families. These experiences of nurses are many a time either underrated or not regarded at all, while evolving a solution to the crisis of medical futility. EXPERIENCES OF NURSES IN VARIOUS FIELDS: Treating adolescent trauma patients: - Providing care for adolescent population in an emergency care unit is really a challenging job for nurses especially those who are in entry level. As the adolescent care differs both from adult care and childcare, the nursing community should possess special skills to face the problems brought out by adolescent trauma patients. Training in this direction is necessary for nurses. (Breslawski JL, 2004). Breslwaski , in this article has aptly suggested the Roy Adaptation Model to clearly understanding the various modes of adapting used by adolescent population. Treatment during postoperative cardiac surgery: - Currey J, Botti M. of Deakin University, Victoria of Australia (2006) is trying to delineate the variability of nurses' haemodynamic decision-making in the immediate follow-up period of cardiac surgery. The study conducted on a sample of 38 nurses revealed that the quality of nurses' decision making was influenced by interplay between complexity of patients' haemodynamic presentations, nurses' cardiac care experiences and the support they derive from their peers and physicians. However no specific suggestions to improve or develop the skill of decision-making by nurses are laid in the article. (Currey J, Botti M,2006 ) Treatment for critically ill diabetic patients: - To reduce the mortality rate of critically ill diabetic patients, Fraser DD, suggested intensive insulin therapy. The study team developed a nomogram and tested its feasibility in clinical usage, accuracy and fastness in comparison with the existing standards in chart form. Nurses found the nomogram highly helpful in improving the accuracy of insulin dosage calculation and the practicability of using the tool by the bedside of the patients was appreciated. (Fraser DD, Robley LR, Ballard NM and Peno-Green LA, 2006). This article simply envisages a technical know-how in the day-to-day works of nurse force. The practicability of using the nomogram is well laid; but the biological implications of the therapy are not discussed. Efficient harnessing of oxygenating equipments: - Turning and positioning of critically ill patients during oxygenation are the nursing activities that need further improving by better understanding by nurses about the different positions of the patients during oxygenation that would improve gas exchange. These parts of the job simultaneously hone the observation skills in nurses. Ability to judge the patients' plight by viewing their facial expressions is developed. (Marklew A, 2006). This is one more article that describes the ways to improve routine jobs of nurses. Managing Cardiac disease in pregnancy: - Pregnant women with cardiac disease are potential challenge to health care nurses. Assessing the imminent problems and resolving them requires in depth-knowledge of gynaecological and cardiac studies. Changes in symptoms would take place very rapidly making the nursing staff confused before landing on a clean land of diagnosis. (Arafeh JM, Baird SM, 2006). The need for specialist care techniques is laid in a nice manner in this article. Critical review of all these journals revealed that most of the nursing teams at the bedside are inexperienced and often unsupported by decision makers. Responsibility of carrying out tasks are shifted to someone else creating gaps and delays in care management which are the problems addressed by the outreach contribution. Outreach may solve the problems for the patients in ICU but the underlying causes remain poorly understood. Technical and clinical guidelines found in these journals are however worth to follow by the nursing team for which the entire nursing community is prepared to accept since every nurse wants to excel in his/her duty by rendering really a care-centred service to patients. Bearing responsibility is the area where the nurses look forward their seniors and physicians and doctors to stamp the authority of their calibre. NURSES' PERCEPTION OF MEDICAL FUTILITY: Professionals in the field at different levels interpret medical futility in different manner. As already stated it is associated with target. Keeping the correct target as to define medical futility varies among doctors, patients, families of patients and co working nurses even. Nothing is more certain than death. But few things raise more questions than health care at the end of life. As medical advances expand treatment options, patients and doctors increasingly disagree about whether certain interventions are beneficial. To help them manoeuvre through ethical landmines, many hospitals and institutions are developing medical futility guidelines to help resolve disputes. How far the patient's or the family's right / autonomy extend Can a doctor allow a patient to die at the discretion of the medical team alone These are the core questions the medical professionals, especially those with decision-making authorities face while considering the non-beneficial treatment. Doctors feel that they are many times put into positions where ethically they consider the prudence of carrying out certain specific courses of treatment would not be humane or would never maintain the dignity of the patients whether they(the patients) are in cognitive state or not. The consumer mentality over the issue of medical futility envisages that people do not have the right to demand treatment that medical professionals deem inappropriate. Physicians should not be required to provide care that is beyond the scope of their skill or judgement. In this atmosphere the doctors consider the right of patient/families as gone wild. Thus physicians invoke most medical futility policies, but nurses and other clinicians are frequently affected by the resulting decisions. Nurses who are well aware of the patients' and families' psychosocial needs are forced to abide by the framed medical futility guidelines against the wish of the families. While removing a life supporting system on a patient in accordance with such guidelines they are put perfectly in an embarrassing corner. Lack of communication between physicians and nurses leads to such anomaly. Underrating of findings of nurses' adds to the problem. Although ethically the primary commitment of nurses is to the patient, they are often in a position to carry out the directive of another person, namely the physician. To arrive at a harmony of opinions all the medical professionals inclusive of doctors, nurses and other clinicians must be allowed to provide their input in evolving a medical futility guideline. The outcome of the decision may still be against the opinion of a constituent member of the team. But the right to provide their input in arriving at a decision would make them work in tune with the framed guideline. The views of patients and their families in the issue of withdrawing a life supporting system or continuing a non-beneficial treatment process should be given proper weight and a consensus arrived at. Otherwise just because of the 'know all' calibre of a doctor, family members would feel that they are coerced to accept the decision of physicians. Some efficient physicians may be talented in convincing others; but the nurses' participation if harnessed in right place and right time would make the families rather 'realise' the entire scenario in the interest of the patient than just being convinced. Use of palliative care services plays a crucial role at this juncture. During the negotiations with the families and patients, the values considered ethical by patient/family and the professional values must both be given respect and accounted for. At times of discrepancies in these values, humility and professional integrity on the part of physicians are essential. (Deborah L. Kasman, 2004)Deborah in his study cleverly identified five questions, which he was to answer during a case-based discussion. Of those five questions, answers to four questions highlighted general pathways to follow, 1. While encountering the differences of opinions with families, 2. While considering the implications of futility decisions, 3. While allowing the professional judgement to dictate and 4. While the professionals are forced to concede the wishes of the family members against the professional judgement. The negotiation process must necessarily move in a direction towards decision regarding treatment options. While doing so the values and beliefs of the family members are ranked against the integrity of health care professionals by Clare M. Clark (2000). In this article the author has established the vacillation between the 'duty of benevolence' and non-obligation to provide futile treatment. Ignoring considerations of justice and fairness is characterised as the quality of 'duty of benevolence'. (Clare M. Clark, 2000) Ross K. Kerridge (2000) of Newcastle honestly admits that the challenge of ensuring appropriate and effective treatment of critically ill patients has politely been ignored. He also encourages the involvement of nursing staff in MET (medical emergency team) developed to provide effective care treatment to critically ill patients. (Ross K. Kerridge, 2000) Michael A. Ashby et al (2005) boldly pointed out the rough side of the 'futility' concept and ascribed the roughness to the uncertainties of medical prognostication. Murray's terming of "prognostic paralysis" had been honestly used to admit the fact that medicine had its own limits. (Michael A. Ashby, Allan Kellehear and Brian F Stoffell, 2005) Communication breaks and lack of communication structure lead to delayed treatment in many hospitals. Enrico W. Coiera et al (2002) conducted a study with a sample of six nursing staff and six doctors at two emergency departments in New South Wales hospitals in 1999. The team concluded that the strained communication is because of the communication loads on clinical staff. They suggested active training to improve the communication systems and optimising the communication processes. The data provided by the team towards the communication channel of 'face-to-face' used mostly by the nursing staff is self evident of their load of communication. (Enrico W Coiera, Rohan A Jayasuriya, Jennifer Hardy, Aiveen Bannan and Max E C Thorpe, 2002) Critical evaluation of the journals makes it clear that nursing staff's perception of medical futility is neither authoritative as that of doctors nor ambitious as that of patient's families. Diligent consideration of their perception of medical futility would evolve a comprehensive guideline acceptable to all concerned. ROLE OF NURSES: The role of nurses in emergency units is comparatively less than their involvement in treating patients outside the limits of ICU. This is "because of their diminished involvement in research activities", says Dawson D. McEwen A.(2005) of London. He conducted a survey in 2003 with a sample of 72 critical care nurse consultants. He opined that nurses' restricted involvement in strategic organisations would limit their developmental role. The survey study however had not attempted to unearth or point out the reasons that prevent nurses from getting involved in the strategic organisations. (Dawson D. McEwen A, 2005). An answer near to get the reasons for such diminished involvement of nursing community in strategic organisations can be obtained from Helend .M (2006). The force applied on nursing communities by the physicians to carry out their directives is ascribed to their less involvement in decision-making processes. (Heland M, 2006). The author of the article suggests the inclusion of nursing staff in ICU related decision-making processes, since understanding patient's and families' views is well managed by them. CONCLUSION: Proliferation in medical technology has stupendously increased the number of diagnostic and therapeutic options available in patient care. Healthcare costs have also mounted as a by-product of these innovations and developments in technology. Simultaneously medical ethics have undergone rapid changes, which is presently focussed towards patients' autonomy. But still the medical prognosis is in the child hood phase of relying entirely upon the clinical feedback. Medical prognosis always and will ever fail in case of foretelling the death of a patient. This being the strength () of the medical prognosis, the professionals now begin to rely on palliative care options for terminally ill patients and patients with critical ailments at ICU. Such caregivers are mainly offering their supporting services derived from nursing communities. Hence the role of nurses, their experiences in ICU and their perception of medical futility make it possible to evolve a medical futility policy acceptable to all concerned. Reference List- Arafeh JM, Baird SM, 2006, "Cardiac disease in pregnancy", Critical Care Nursing Q, 29(1):32-52 Breslawski JL, "Caring for the adolescent trauma patient in the adult critical care setting.",2004, Journal of Trauma Nursing,11(3):111-6 Clare M. Clark, 2000, "Do parents or surrogates have the right to demand treatment deemed futile-An analysis of the case", Journal of Advanced Nursing, Vol. 32, Issue 3, page 757 Currey J, Botti M,2006, "The influence of patient complexity and nurses' experience on haemodynamic decision-making following cardiac surgery", Intensive Critical Care Nursing, doi:22nd March 2006 Dawson D. McEwen A, 2005, "Critical care without walls:The role of nurse consultant in critical care", Intensive Critical Care Nursing, 21(6):334-343, Epub Deborah L. Kasman, 2004, "When is medical treatment futile", Journal of General Internal Medicine, Vol.19 Issue 10 page 1053-1056 Enrico W Coiera, Rohan A Jayasuriya, Jennifer Hardy, Aiveen Bannan and Max E C Thorpe,2002, "Communication loads on clinical staff in the emergency department", Medical Journal of Australia,176 (9):415-418 Fraser DD, Robley LR, Ballard NM and Peno-Green LA, 2006, "Collaborative development of an insulin nomogram for intensive insulin therapy", Critical Care Nurse Q, 29(1):96-105 Heland M, 2006, "Fruitful or futile:intensive care nurses' experiences and perceptions of medical futility", Australian Critical Care, 19(1):25-31 Marklew A, 2006, "Body positioning and its effect on oxygenation-a literature review", Nursing Critical Care,11(1):16-22 Michael A. Ashby, Allan Kellehear and Brian F Stoffell, 2005, "Resolving conflict in the end-of-life care", Medical Journal of Australia,183(5):230-231 Ross K. Kerridge, 2000, "The medical emergency team: no evidence to justify not implementing change", Medical Journal of Australia,173:228-229 Read More