title: Exploring Australian intensive care physicians clinical judgement during Donation after Cardiac Death: an exploratory qualitative study.
abstract: BACKGROUND
  Donation after Cardiac Death (DCD) is one possible solution to the world wide organ shortage. Intensive care physicians are central to DCD becoming successful since they are responsible for making the clinical judgements and decisions associated with DCD. Yet international evidence shows health care professionals have not embraced DCD and are often reluctant to consider it as an option for patients.
  
  
  OBJECTIVE
  To explore intensive care physicians' clinical judgements when selecting a suitable DCD candidate.
  
  
  METHODS
  Using interpretative exploratory methods six intensive care physicians were interviewed from three hospital sites in Australia. Following verbatim transcription, data was subjected to thematic analysis.
  
  
  RESULTS
  Three distinct themes emerged. Reducing harm and increasing benefit was a major focus of intensive care physicians during determination of DCD. There was an acceptance of DCD if there was clear evidence that donation was what the patient and family wanted. Characteristics of a defensible decision reflected the characteristics of sequencing, separation and isolation, timing, consensus and collaboration, trust and communication to ensure that judgements were robust and defensible. The final theme revealed the importance of minimising uncertainty and discomfort when predicting length of survival following withdrawal of life-sustaining treatment.
  
  
  CONCLUSIONS
  DCD decisions are made within an environment of uncertainty due to the imprecision associated with predicting time of death. Lack of certainty contributed to the cautious and collaborative strategies used by intensive care physicians when dealing with patients, family members and colleagues around end-of-life decisions, initiation of withdrawal of life-sustaining treatment and the discussion about DCD. This study recommends that nationally consistent policies are urgently needed to increase the degree of certainty for intensive care staff concerning the DCD processes.
authors.affiliation: John Hunter Hospital, Newcastle, NSW, Australia. Electronic address: mailnicolecoleman@gmail.com.
authors.forename: Nicole L
authors.initials: NL
authors.lastname: Coleman
authors.affiliation: School of Nursing, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059, Australia. Electronic address: ann.bonner@qut.edu.au.
authors.forename: Ann
authors.initials: A
authors.lastname: Bonner
mesh_terms: D003422:Critical Care; D003643:Death; D003657:Decision Making; D006801:Humans; D007407:Interviews as Topic; D009517:New South Wales; D010820:Physicians / Q000523:psychology*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D036301:Qualitative Research; D009927:Tissue and Organ Procurement
keywords: Care & Decision; Donation after Cardiac Death; End-of-life care & decision making; Transplantation