Variations in reporting of nurse involvement in end-of-life practices in intensive care units worldwide (ETHICUS-2): A prospective observational study

Julie Benbenishty; Freda DeKeyser Ganz; Alexandre Lautrette; Ulrich Jaschinski; Avneep Aggarwal; Eldar Søreide; Manfred Weiss; Knut Dybwik; Elif Ayşe Çizmeci; Roberto Carlos Miranda Ackerman; Belén Estebanez-Montiel; Bara Ricou; Annette Robertsen; Charles L Sprung; Alexander Avidan

doi:10.1016/j.ijnurstu.2024.104764

Variations in reporting of nurse involvement in end-of-life practices in intensive care units worldwide (ETHICUS-2): A prospective observational study

Int J Nurs Stud. 2024 Apr 11:155:104764. doi: 10.1016/j.ijnurstu.2024.104764. Online ahead of print.

Authors

Affiliations

¹ Hadassah Hebrew University Medical Center and School of Nursing Jerusalem Israel, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel. Electronic address: julie@hadassah.org.il.
² Hadassah Hebrew University Medical Center and School of Nursing Jerusalem Israel, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel; Faculty of Life and Health Sciences, Jerusalem College of Technology, Jerusalem, Israel.
³ Department of Intensive Care Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France.
⁴ Department of Anaesthesiology and Critical Care, University Hospital Augsburg, Germany.
⁵ Department of General Anesthesiology, Department of Intensive Care and Resuscitation Cleveland Clinic, OH, USA.
⁶ Section for Quality and Patient Safety, Stavanger University Hospital and Faculty of Health Sciences University of Stavanger, Stavanger, Norway.
⁷ Clinic for Anaesthesiology and Intensive Care Medicine, University of Ulm, Germany.
⁸ Intensive Care Unit, Nordland Hospital, Bodø, Norway.
⁹ University of Toronto, Faculty of Medicine, Interdepartmental Division of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada.
¹⁰ Intensive Care Unit of Hospital San Javier, Guadalajara, Mexico.
¹¹ Intensive Medicine Department, University Hospital La Paz, Madrid, Spain.
¹² Intensive Care of Geneva, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva Hospital and University of Geneva, Switzerland.
¹³ Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway; Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.
¹⁴ Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
¹⁵ Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Ein Kerem Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.

PMID: 38657432
DOI: 10.1016/j.ijnurstu.2024.104764

Abstract

Background: ICU nurses are most frequently at the patient's bedside, providing care for both patients and family members. They perform an essential role and are involved in decision-making. Despite this, research suggests that nurses have a limited role in the end-of-life decision-making process and are occasionally not involved.

Objective: Explore global ICU nurse involvement in end of life decisions based on the physician's perceptions and sub-analyses from the ETHICUS-2 study.

Design: This is a secondary analysis of a prospective multinational, observational study of the ETHICUS-2 study.

Setting: End of life decision-making processes in ICU patients were studied during a 6-month period between Sept 1, 2015, and Sept 30, 2016, in 199 ICUs in 36 countries.

Intervention: None.

Methods: The ETHICUS II study instrument contained 20 questions. This sub-analysis addressed the four questions related to nurse involvement in end-of-life decision-making: Who initiated the end-of-life discussion? Was withholding or withdrawing treatment discussed with nurses? Was a nurse involved in making the end-of-life decision? Was there agreement between physicians and nurses? These 4 questions are the basis for our analysis. Global regions were compared.

Results: Physicians completed 91.8 % of the data entry. A statistically significant difference was found between regions (p < 0.001) with Northern Europe and Australia/New Zealand having the most discussion with nurses and Latin America, Africa, Asia and North America the least. The percentages of end-of-life decisions in which nurses were involved ranged between 3 and 44 %. These differences were statistically significant. Agreement between physicians and nurses related to decisions resulted in a wide range of responses (27-86 %) (p < 0.001). There was a wide range of those who replied "not applicable" to the question of agreement between physicians and nurses on EOL decisions (0-41 %).

Conclusion: There is large variability in nurse involvement in end-of-life decision-making in the ICU. The most concerning findings were that in some regions, according to physicians, nurses were not involved in EOL decisions and did not initiate the decision-making process. There is a need to develop the collaboration between nurses and physicians. Nurses have valuable contributions for best possible patient-centered decisions and should be respected as important parts of the interdisciplinary team.

Tweetable abstract: Wide global differences were found in nurse end of life decision involvement, with low involvement in North and South America and Africa and higher involvement in Europe and Australia/New Zealand.

Keywords: Critical care; Decision-making; End of life; Intensive care; Nurses.