title: End-of-life decisions in the Intensive Care Unit (ICU) - Exploring the experiences of ICU nurses and doctors - A critical literature review.
abstract: BACKGROUND
  End-of-life decision making in the Intensive Care Unit (ICU), can be emotionally challenging and multifaceted. Doctors and nurses are sometimes placed in a precarious position where they are required to make decisions for patients who may be unable to participate in the decision-making process. There is an increasing frequency of the need for such decisions to be made in ICU, with studies reporting that most ICU deaths are heralded by a decision to withdraw or withhold life-sustaining treatment.
  
  
  OBJECTIVE
  The purpose of this paper is to critically review the literature related to end-of-life decision making among ICU doctors and nurses and focuses on three areas: (1) Who is involved in end-of-life decisions in the ICU?; (2) What challenges are encountered by ICU doctors and nurses when making decisions?; and (3) Are these decisions a source of moral distress for ICU doctors and nurses?
  
  
  METHODS
  This review considered both qualitative and quantitative research conducted from January 2006 to March 2014 that report on the experiences of ICU doctors and nurses in end-of-life decision making. Studies with a focus on paediatrics, family/relatives perspectives, advance care directives and euthanasia were excluded. A total of 12 papers were identified for review.
  
  
  RESULTS
  There were differences reported in the decision making process and collaboration between doctors and nurses (which depended on physician preference or seniority of nurses), with overall accountability assigned to the physician. Role ambiguity, communication issues, indecision on futility of treatment, and the initiation of end-of-life discussions were some of the greatest challenges. The impact of these decisions included decreased job satisfaction, emotional and psychological 'burnout'.
  
  
  CONCLUSIONS
  Further research is warranted to address the need for a more comprehensive, standardised approach to support clinicians (medical and nursing) in end-of-life decision making in the ICU.
authors.affiliation: University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia. Electronic address: l.flannery@uws.edu.au.
authors.forename: Liz
authors.initials: L
authors.lastname: Flannery
authors.affiliation: University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia. Electronic address: l.ramjan@uws.edu.au.
authors.forename: Lucie Michelle
authors.initials: LM
authors.lastname: Ramjan
authors.affiliation: University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia. Electronic address: k.peters@uws.edu.au.
authors.forename: Kath
authors.initials: K
authors.lastname: Peters
mesh_terms: D003657:Decision Making; D006801:Humans; D007362:Intensive Care Units; D009741:Nursing Staff, Hospital / Q000523:psychology*; D010820:Physicians / Q000523:psychology*; D013727:Terminal Care
keywords: Critical care; Decision making; Doctors; End of life; Intensive care; Nurses