Barriers and Facilitators to End-of-Life Care Delivery in ICUs: A Qualitative Study.

Objectives: To understand frontline ICU clinician's perceptions of end-of-life care delivery in the ICU.
Design: Qualitative observational cross-sectional study.
Setting: Seven ICUs across three hospitals in an integrated academic health system.
Subjects: ICU clinicians (physicians [critical care, palliative care], advanced practice providers, nurses, social workers, chaplains).
Interventions: None.
Measurements and Main Results: In total, 27 semi-structured interviews were conducted, recorded, and transcribed. The research team reviewed all transcripts inductively to develop a codebook. Thematic analysis was conducted through coding, category formulation, and sorting for data reduction to identify central themes. Deductive reasoning facilitated data category formulation and thematic structuring anchored on the Systems Engineering Initiative for Patient Safety model identified that work systems (people, environment, tools, tasks) lead to processes and outcomes. Four themes were barriers or facilitators to end-of-life care. First, work system barriers delayed end-of-life care communication among clinicians as well as between clinicians and families. For example, over-reliance on palliative care people in handling end-of-life discussions prevented timely end-of-life care discussions with families. Second, clinician-level variability existed in end-of-life communication tasks. For example, end-of-life care discussions varied greatly in process and outcomes depending on the clinician leading the conversation. Third, clinician-family-patient priorities or treatment goals were misaligned. Conversely, regular discussion and joint decisions facilitated higher familial confidence in end-of-life care delivery process. These detailed discussions between care teams aligned priorities and led to fewer situations where patients/families received conflicting information. Fourth, clinician moral distress occurred from providing nonbeneficial care. Interviewees reported standardized end-of-life care discussion process incorporated by the people in the work system including patient, family, and clinicians were foundational to delivering end-of-life care that reduced both patient and family suffering, as well as clinician moral distress.
Conclusions: Standardized work system communication tasks may improve end-of life discussion processes between clinicians and families.
Competing Interests: Dr. Janczewski received support for article research from the Agency for Healthcare Research and Quality (5F32HS027724-02). Dr. Ko’s institution received funding from the National Institutes of Health (NIH); he received support for article research from the NIH. Dr. Yang disclosed work for hire. Dr. Kruser disclosed that her spouse receives funding from AstraZeneca and Radialogica. Dr. Stey received funding from American Association for the Surgery of Trauma, American College of Surgeons, and the National Heart, Lung, and Blood Institute. The remaining authors have disclosed that they do not have any potential conflicts of interest.
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