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Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative study

Abstract

Purpose

Our aim was to explore reasons for physician variability in decisions to limit life support in the intensive care unit (ICU) utilizing qualitative methodology.

Methods

Single center study consisting of semi-structured interviews with experienced physicians and nurses. Seventeen intensivists from medical (n = 7), surgical (n = 5), and anesthesia (n = 5) critical care backgrounds, and ten nurses from medical (n = 5) and surgical (n = 5) ICU backgrounds were interviewed. Principles of grounded theory were used to analyze the interview transcripts.

Results

Eleven factors within four categories were identified that influenced physician variability in decisions to limit life support: (1) physician work environment—workload and competing priorities, shift changes and handoffs, and incorporation of nursing input; (2) physician experiences—of unexpected patient survival, and of limiting life support in physician’s family; (3) physician attitudes—investment in a good surgical outcome, specialty perspective, values and beliefs; and (4) physician relationship with patient and family—hearing the patient’s wishes firsthand, engagement in family communication, and family negotiation.

Conclusions

We identified several factors which physicians and nurses perceived were important sources of physician variability in decisions to limit life support. Ways to raise awareness and ameliorate the potentially adverse effects of factors such as workload, competing priorities, shift changes, and handoffs should be explored. Exposing intensivists to long term patient outcomes, formalizing nursing input, providing additional training, and emphasizing firsthand knowledge of patient wishes may improve decision making.

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Acknowledgments

The authors would like to thank J. Randall Curtis MD, MPH for his thoughtful guidance and manuscript review. Financial/non financial disclosures: Financial Support was provided by Mayo Clinic Sponsorship Board and Mayo Foundation.

Conflicts of interest

The authors have no conflicts of interest to disclose.

Author information

Correspondence to Michael E. Wilson.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOC 40 kb)

Appendix: interview guide questions

Appendix: interview guide questions

For physicians:

  1. 1.

    How do you (or intensivists) make decisions to limit or continue life support?

    1. a.

      What factors influence decisions to limit or continue life support?

For nurses:

  1. 1.

    How do physicians make decisions to limit or continue life support?

    1. a.

      What factors influence decisions to limit or continue life support?

    2. b.

      What is your role as a nurse in making/contributing to decisions about continuing or limiting life support?

For physicians and nurses:

  1. 2.

    Prior research has established that both patient preference and patient prognosis are strong influences in the decision to limit life support. Aside from the patient’s life support preferences and aside from the patient’s prognosis, which other factors influence the decision to limit life support?

  2. 3.

    Why do physicians make varying decisions to limit or continue life support?

    1. a.

      Suppose two different physicians were treating the same patient, what factors would lead different decisions being made?

    2. b.

      Can you give an example?

  3. 4.

    What does it mean to withdraw life support prematurely?

    1. a.

      Can you give an example of when life support was withdrawn prematurely?

    2. b.

      Which factors led to premature withdrawal of life support?

  4. 5.

    What does it mean to continue life support unnecessarily?

    1. a.

      Can you given an example of when life support was continued unnecessarily?

    2. b.

      Which factors led to life support being continued unnecessarily?

  5. 6.

    Have you ever disagreed with another provider about the decision to limit life support?

    1. a.

      Can you give an example of when life support was withdrawn and you disagreed?

    2. b.

      Why did you disagree?

    3. c.

      Can you give an example of when life support was continued and you disagreed?

    4. d.

      Why did you disagree?

  6. 7.

    Have you ever felt regret regarding a decision to limit or continue life support?

  7. 8.

    Describe a situation in which a decision was made to limit life support and the end result was what you believed to be a good outcome.

    1. a.

      What made it a good outcome?

  8. 9.

    Describe a situation in which a decision was made to limit life support and the end result was what you believed to be a poor outcome.

    1. a.

      What made it a poor outcome?

  9. 10.

    What interventions would you propose that could improve life support decision making?

  10. 11.

    Is there anything else you would like to share about this topic?

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Wilson, M.E., Rhudy, L.M., Ballinger, B.A. et al. Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative study. Intensive Care Med 39, 1009–1018 (2013). https://doi.org/10.1007/s00134-013-2896-x

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Keywords

  • Intensive care
  • Life support care
  • Withholding treatment
  • Decision making
  • Physician’s role
  • Terminal care