title: Negotiated dying: a grounded theory of how nurses shape withdrawal of treatment in hospital critical care units.
abstract: BACKGROUND
  The process of withdrawal of treatment in critical care environments has created ethical and moral dilemmas in relation to end of life care in the UK and elsewhere. Common within this discourse is the differing demands made on health professionals as they strive to provide care for the dying patient and family members. Despite reports that withdrawal of treatment is a source of tension between those nurses and doctors involved in the process, the role of the nurse in facilitating withdrawal of treatment has received relatively little attention.
  
  
  OBJECTIVE
  To illustrate how differing dying trajectories impact on decision-making underpinning withdrawal of treatment processes, and what nurses do to shape withdrawal of treatment.
  
  
  METHODS
  Qualitative methods of enquiry using clinical vignettes and applying Charmaz's grounded theory method.
  
  
  METHODS
  Single audio-recorded qualitative interviews with thirteen critical care nurses from four intensive care specialities: cardiac; general; neurological and renal were carried out. Interviews were facilitated by an end-of-life vignette developed with clinical collaborators.
  
  
  RESULTS
  Across critical care areas four key dying trajectories were identified. These trajectories were shaped by contested boundaries associated with delayed or stalled decision-making around how withdrawal of treatment should proceed. Nurses provided end of life care (including collaborative and action-oriented skills) to shape the dying trajectory of patients so as to satisfy the wishes of the patient and family, and their own professional aims.
  
  
  CONCLUSIONS
  Differing views as to when withdrawal of treatment should commence and how it should be operationalised appeared to be underpinned by the requirements of the role that health professionals fulfil, with doctors focusing on making withdrawal of treatment decisions, and nurse's being tasked with operationalising the processes that constitute it. Multidisciplinary teams need a 'shared' understanding of each other's roles, responsibilities, aims, and motivations when planning and implementing the dying trajectory of withdrawal of treatment.
authors.affiliation: Faculty of Health Sciences, Building 67, University of Southampton, Southampton SO17 1BJ, United Kingdom. T.Long@soton.ac.uk
authors.forename: Tracy
authors.initials: T
authors.lastname: Long-Sutehall
authors.forename: Helen
authors.initials: H
authors.lastname: Willis
authors.forename: Rachel
authors.initials: R
authors.lastname: Palmer
authors.forename: Debra
authors.initials: D
authors.lastname: Ugboma
authors.forename: Julia
authors.initials: J
authors.lastname: Addington-Hall
authors.forename: Maureen
authors.initials: M
authors.lastname: Coombs
mesh_terms: D003422:Critical Care; D003643:Death; D006801:Humans; D017008:Negotiating; D009741:Nursing Staff, Hospital