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Research vignette, Continued
Physicians in more northern regions reported more nurse conflicts. Data on perceived conflicts in the week prior to the
involvement. survey day were obtained from 7498 ICU staff members (323 ICUs
in 24 countries). Conflicts were perceived by 5268 (71.6%) respon-
Conclusions
Physicians perceive nurses as involved to a large extent in EOLDs, dents. Nurse-physician conflicts were the most common (32.6%),
but not as initiating the discussion. Once a decision is made, there although doctors were less likely to report conflicts than were
is a sense of agreement. The level of perceived participation is dif- other staff members. This emphasises the lack of reliability of using
ferent for different regions. physician reports as the data collection method in the ETHICUS
study.
Critique The ETHICUS study found significant geographical and regional
This study explored ICU physicians’ perceptions of nurse involve- differences that influenced physicians’ perceptions of nurses’ EOL
ment. The underlying assumptions in this study are potentially participation. Nurses in northern Europe were perceived to be
flawed for a number of reasons. First, nurses and physicians are more involved in such decisions. These differences might reflect
known to communicate differently and to hold different percep- variants in the working cultures and professional roles within dif-
tions regarding the quality of collaboration and communication. ferent regions. Nurses in the northern region may have a more
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It is therefore possible that physicians’ perceptions bear no rela- collegial role with physicians with respect to EOLDs. These
tionship to levels of actual nurse involvement. It would have been responses might also be due to the considerable variation across
beneficial to explore the similarities and differences between phy- Europe that exists in the legislation and practice of withdrawing
sicians’ and nurses’ perceptions in this important, and often diffi- and withholding treatment. For example, Rubulotta relates
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cult, area of clinical decision making.
that the Italian National Society of Anaesthesia, Analgesia, Resus-
Second, the data were collected and submitted by senior ICU phy- citation and Intensive Care has stated, ‘still it seems that the physi-
sician decision makers at each institution. It is not clear what clini- cian (single person) should ultimately decide to limit care by either
cal involvement or work patterns these physicians had and not initiating or suspending intensive care in a specific patient’.
therefore whether they were familiar with the practices under- Culturally, Italian families expect doctors to make final EOL deci-
taken throughout the 24 hours of each day, or primarily involved sions. As a consequence, nursing staff may not be asked for their
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in the discussions and decisions that occur during ‘office hours’. opinion or families may be unwilling to discuss EOL issues with
nurses.
There is little information provided in this report detailing the
method used to collect the study data, although further details can A further concern raised by the results is that 17% of respondents
be gained by accessing an additional publication. It is not clear indicated the question regarding agreement between nurses and
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how participation in the study was sought, nor whether the centres physicians was not applicable. The reason behind this lack of appli-
that participated were representative of European ICUs in general. cability is not clear. It is possible the physicians thought the ques-
Given that only 37 centres in 17 countries, or an average of only tion was inappropriate because of no disagreement in the area, or
two centres in each country participated, the results may not be alternatively that they considered nurses should not be involved
representative of practice and decision making across each in such decisions and therefore any question about their participa-
country. tion was inappropriate.
Bearing in mind the above limitations, the physicians in this study While this study report raises more questions than it answers, it
indicated a high level of agreement between nurses and physicians does emphasise the importance of EOLD and the need for improved
in EOLD. This is in contrast to the evidence that conflicts are processes throughout the international practice arena. Families of
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common and harmful in the ICU. Instances where physicians critically ill patients generally benefit from receiving consistent
relate nurses’ practice often lead to discrepancies and conflicts. information from all members of the health care team. As a result
Azoulay et al. attempted to measure the extent of conflicts occur- implementation of strategies to optimise involvement of all
ring in global ICUs, in an international study. The CONFLICUS members of the health care team and ensure agreement between
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study was a one-day cross-sectional survey of ICU clinicians nurses and physicians and the delivery of a consistent message are
recording the prevalence, characteristics, and factors of ICU likely to be beneficial.

Learning activities

Learning activities 1–4 relate to the Case study. 5. Because critical care patients are often incompetent and
1. What might be some of the positive aspects of caring for unable to provide informed consent for procedures, consent is
patients like Mary? often implied. What are the boundaries of implied consent, and
2. What might be some of the challenging aspects of caring for a what must critical care nurses be conscious of in relying on
patient like Mary? implied consent for treatment?
3. What considerations or issues should be taken into account by 6. The ANMC Code of Ethics for Nurses contains six broad value
the healthcare team when making decisions in the care of a statements (see Box 5.1). Reflect on the degree to which your
similar patient? practice demonstrates these values. Consider how these values
4. What strategies may be useful for staff to adopt when caring relate to critical care practice. Discuss these values with your
for culturally challenging patients in critical care? critical care colleagues.