Looking for certainty: End-of-life decision making in acute care

Abstract

In acute medical settings, doctors and nurses routinely use clinical decision-making skills in order to determine when, how and to whom end-of-life care is delivered. Yet, there has been little investigation into how clinicians working in acute medicine describe the process of end-of-life decision making. This is problematic given the frequency with which end-of-life care is provided in acute medical wards, and evidence of inadequacies in the way that end-of-life care is currently managed.

The aim of this exploratory, mixed method study was to explore and describe end-of-life decision making on an acute medical ward in a tertiary centre in New Zealand. The study was conducted in two phases. In phase 1, the medical records of 24 deceased patients, whose deaths were expected, were retrospectively reviewed to identify clinical and end-of-life characteristics of the population. Data concerning the timing and nature of documented end-of-life decisions were also analysed using descriptive statistics. The mean age for the population was 80.4 years, and 88% (n=21) of patients had three or more chronic conditions. 50% (n=12) were admitted with, and died from, pneumonia. There was a mean of 4.5 days (range 3 hours – 17 days) between the first documented indication that a patient’s recovery was unlikely, and the time of death. In 92% (n=22) of patients there was documented evidence of discussion with family members. There was no evidence of patient involvement in end-of-life decision-making. These findings informed the second, qualitative, phase.

Three semi-structured interviews and five focus groups were conducted with a total of 28 doctors and nurses working in the ward, to explore their experiences and perspectives of end-of-life decision-making. Thematic analysis of the qualitative findings was conducted. Two themes were developed from the data. The first theme, ‘antecedents of uncertainty’, described the impact of the acute medical setting on end-of-life care, and individual variability in attitudes and experiences of end-of-life decision making. A second theme, ‘moving forward with certainty’ described strategies used to navigate the uncertain and decide on an agreed path for end-of-life care.

Whilst a single centre study using a small sample size has limitations, this work contributes new knowledge regarding the nature of end-of-life decision making on an acute medical ward. To improve end-of-life decision-making in this setting, patient-centred strategies for navigating uncertainty are needed. This requires early identification of the trajectory of dying and of patient preferences at end of life. Inclusive strategies supporting all staff to participate in timely end-of-life decisions are needed.