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Impact of Physicians' Behaviors on the Family

Virginia P. Tilden, RN, DNSc, FAAN; Susan W. Toile, MD; Michael J. Garland, DScRel; Christine A. Nelson, RN, MS

Arch Intern Med. 1995;155(6):633-638.

Abstract
Background
Despite the growing availability of advance directives, most patients in the intensive care unit lack written directives, and, therefore, consultation with families about treatment decisions remains the rule. In the context of decision making about withdrawing life-sustaining treatments, we investigated which physician and nurse behaviors families find supportive and which behaviors increase the family's burden.

Methods
We conducted intensive 1- to 2-hour-long individual interviews using a semistructured interview protocol with 32 family members of patients without advance directives whose deaths followed a stay in the intensive care unit and withdrawal of treatment. We analyzed more than 700 pages of verbatim interview data using content analysis techniques and achieved more than 90% interrater agreement on data codes.

Results
Themes emerged as families identified selected physician and nursing behaviors as helpful: encouraging advanced planning, timely communication, clarification of families' roles, facilitating family consensus, and accommodating family's grief. Behaviors that made families feel excluded or increased their burden included postponing discussions about treatment withdrawal, delaying withdrawal once scheduled, placing the full burden of decision making on one person, withdrawing from the family, and defining death as a failure.

Conclusions
Study findings provide an increased understanding of the unmet needs of families and serve to guide physicians and nurses in reducing actions that increase families' burdens as they participate in treatment withdrawal decisions.

(Arch Intern Med. 1995;155:633-638)

Author Affiliations
From the School of Nursing (Dr Tilden), Center for Ethics in Health Care (Drs Tilden, Tolle, and Garland), Division of General Internal Medicine (Dr Tolle), Department of Public Health and Preventive Medicine (Dr Garland), and School of Nursing Office of Research Development and Utilization (Ms Nelson), Oregon Health Sciences University, Portland.

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