title: Practice of expert critical care nurses in situations of prognostic conflict at the end of life.
abstract: BACKGROUND
  Prolonging the living-dying process with inappropriate treatment is a profoundly disturbing ethical issue for nurses in many practice areas, including the intensive care unit. Despite the frequent occurrence of such distressing events, research suggests that critical care nurses assume a limited role in end-of-life decision making and care planning.
  
  
  OBJECTIVE
  To explore the practice of expert critical care nurses in end-of-life conflicts and to describe actions taken when the nurses thought continued aggressive medical interventions were not warranted.
  
  
  METHODS
  A qualitative design was used with narrative analysis of interview data that had a temporal ordering of events. Interviews were conducted with 21 critical care nurses from 7 facilities in the southwestern United States who were nominated as experts by their colleagues.
  
  
  RESULTS
  Three recurrent narrative plots were derived: protecting or speaking for the patient, presenting a realistic picture, and experiencing frustration and resignation. Narratives of protecting or speaking for the patient concerned preventing further technological intrusion and thus permitting a dignified death. Presenting a realistic picture involved helping patients' family members reframe the members' sense of the potential for recovery. Inability to affect a patient's situation was expressed in narratives of frustration and resignation.
  
  
  CONCLUSIONS
  The transition from curative to end-of-life care in the intensive care unit is often fraught with ambiguity and anguish. The expert nurses demonstrated the ability and willingness to actively protect and advocate for their vulnerable patients even in situations in which the nurses' actions did not influence the outcomes.
authors.affiliation: Schools of Nursing, University of Texas Health Science Center, San Antonio, TX, USA. robichaux@uthscsa.edu
authors.forename: Catherine McBride
authors.initials: CM
authors.lastname: Robichaux
authors.forename: Angela P
authors.initials: AP
authors.lastname: Clark
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D001293:Attitude to Death; D003220:Conflict, Psychological; D003422:Critical Care / Q000379:methods* / Q000523:psychology; D016638:Critical Illness / Q000451:nursing*; D003657:Decision Making; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D024802:Nurse's Role; D009723:Nurse-Patient Relations; D010344:Patient Advocacy; D011368:Professional-Family Relations; D011379:Prognosis; D013727:Terminal Care / Q000379:methods* / Q000523:psychology; D014481:United States