title: Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative study.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. wilson.michael1@mayo.edu
authors.forename: Michael E
authors.initials: ME
authors.lastname: Wilson
authors.forename: Lori M
authors.initials: LM
authors.lastname: Rhudy
authors.forename: Beth A
authors.initials: BA
authors.lastname: Ballinger
authors.forename: Ann N
authors.initials: AN
authors.lastname: Tescher
authors.forename: Brian W
authors.initials: BW
authors.lastname: Pickering
authors.forename: Ognjen
authors.initials: O
authors.lastname: Gajic
mesh_terms: D001291:Attitude of Health Personnel; D002983:Clinical Competence; D064648:Critical Care Nursing; D003657:Decision Making; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007407:Interviews as Topic; D008020:Life Support Care; D008297:Male; D016134:Organizational Policy; D062209:Patient Handoff; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011368:Professional-Family Relations; D011369:Professional-Patient Relations; D036301:Qualitative Research; D028761:Withholding Treatment; D016526:Workload
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