title: Attitudes of legal guardians in the ICU - a qualitative report.
abstract: Decision-making in intensive care units (ICUs) is often made by surrogates, since patients are unconscious or incompetent. In Israel, Legal Guardians (LGs), appointed by the court, are required to make these decisions.
  
  
  OBJECTIVE
  To qualitatively assess the attitudes of LGs required to make decisions on behalf of their relatives.
  
  
  METHODS
  Demographic and semi-structured questionnaires were used to assess the attitudes of LGs regarding difficulties, positive aspects and areas for improvement with regard to surrogate decision-making. The study sampled sixty-four LGs in two large Israeli hospitals. After reading and analysing the responses provided by the LGs, the authors categorised the pertinent topics raised using a thematic analysis.
  
  
  RESULTS
  Themes were: bureaucratic and legal issues, unclear or unknown patient preferences and fear of outcomes. Family and medical staff support was stated as the most beneficial. Suggestions for improvement included alleviation of bureaucracy and improved communication with the medical staff.
  
  
  CONCLUSIONS
  The importance of communication and bureaucratic difficulties, making the best decision for the patient and uncertainty regarding decision outcomes were found to be important issue for the LGs. The healthcare team should try and alleviate some of these burdens, mostly by improving communication with relatives, stressing and educating the importance of advance directives. Reporting the problems found in the decision making process of LGs to the legislators in order to revise and simplify the current legal requirements is advised.
authors.affiliation: General ICU, Assaf Harofeh Medical Center, Beer Jaacov 70300, Israel; The Hebrew University Hadassah School of Public Health and Community Medicine, Faculty of Medicine, Israel. Electronic address: kuniavsk.michael@mail.huji.ac.il.
authors.forename: Michael
authors.initials: M
authors.lastname: Kuniavsky
authors.affiliation: Medical ICU, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Peter V
authors.initials: PV
authors.lastname: van Heerden
authors.affiliation: Hadassah-Hebrew University School of Nursing, Faculty of Medicine, Jerusalem, Israel.
authors.forename: Ilana
authors.initials: I
authors.lastname: Kadmon
authors.affiliation: Hadassah-Hebrew University School of Nursing, Faculty of Medicine, Jerusalem, Israel.
authors.forename: Freda
authors.initials: F
authors.lastname: Dekeyser Ganz
authors.affiliation: Medical ICU, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: David M
authors.initials: DM
authors.lastname: Linton
authors.affiliation: Medical ICU, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Sigal
authors.initials: S
authors.lastname: Sviri
mesh_terms: D000328:Adult; D016223:Advance Directives; D001290:Attitude; D003142:Communication; D064648:Critical Care Nursing; D016638:Critical Illness; D003657:Decision Making; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007872:Legal Guardians / Q000523:psychology; D008297:Male; D008875:Middle Aged
keywords: ICU; Legal Guardian; Qualitative research; Surrogate decision making