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Life Support in the Intensive Care Unit a Qualitative Investigation of Technological Purposes

Life Support in the Intensive Care Unit a Qualitative Investigation of Technological Purposes

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Published by vasiliki
Deborah J. Cook, MD*, Mita Giacomini, PhD, Nancy Johnson, MA, Dennis Willms, PhD and For the Canadian Critical Care Trials Group
Deborah J. Cook, MD*, Mita Giacomini, PhD, Nancy Johnson, MA, Dennis Willms, PhD and For the Canadian Critical Care Trials Group

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Published by: vasiliki on Apr 01, 2011
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Life support in the intensive care unit: a qualitativeinvestigation of technological purposes
 Deborah J. Cook, MD*, Mita Giacomini, PhD, NancyJohnson, MA, Dennis Willms, PhD and For the CanadianCritical Care Trials Group
From the Departments of *Medicine, Clinical Epidemiology and Anthropology, and the Centre For Health Economicsand Policy Analysis, McMaster University, Hamilton, Ont.Abstract 
 The ability of many intensive care unit (ICU) technologies
to prolong life has led to an outcomes-oriented approachto
technology assessment, focusing on morbidity andmortality as
clinically important end points. With advancedlife support,
however, the therapeutic goals sometimesshift from extending
life to allowing life to end. Theobjective of this study was
to understand the purposes forwhich advanced life support is
withheld, provided,continued or withdrawn in the ICU.
 In a 15-bed ICU in a university-affiliated hospital,
theauthors observed 25 rounds and 11 family meetings inwhich
withdrawal or withholding of advanced life supportwas addressed.
Semi-structured interviews wereconducted with 7 intensivists,
5 consultants, 9 ICU nurses,the ICU nutritionist, the hospital
ethicist and 3 pastoralservices representatives, to discuss
patients about whomlife support decisions were made and to
discuss life-support practices in general. Interview transcripts
andfield notes were analysed inductively to identify andcorroborate
emerging themes; data were coded followingmodified grounded
theory techniques. Triangulationmethods included corroboration
among multiple sources of 
data, multidisciplinary team consensus,
sharing of resultswith participants and theory triangulation.
 Although life-support technologies are traditionally
deployed to treat morbidity and delay mortality in ICUpatients,
they are also used to orchestrate dying.Advanced life support
can be withheld or withdrawn tohelp determine prognosis. The
tempo of withdrawalinfluences the method and timing of death.
Decisions towithhold, provide, continue or withdraw life support
aresocially negotiated to synchronize understanding andexpectations
among family members and clinicians. Indiscussions, one discrete
life support technology issometimes used as an archetype for
the more generalconcept of technology. At other times, life-support
technologies are discussed collectively to clarify thepursuit
of appropriate goals of care.
 The orchestration of death involves process-oriented
aswell as outcome-oriented uses of technology. These usesshould
be considered in the assessment of life-supporttechnologies
and directives for their appropriate use in theICU.
Critical care medicine provides 2 major services forseriously
ill patients: intense and sometimes invasivediagnosis and monitoring,
to allow early recognition andtreatment of biomedical problems,
and advanced lifesupport, to improve the short, and possibly
long-termsurvival of patients with exigent, life-threatening
Critical care medicine uses state-of-the-art technology
topursue its mission.
The dramatic ability of many intensive care unit (ICU)technologies
to prolong life has led to an outcomes-oriented approach to
technology assessment, focusing onmorbidity and mortality as
clinically important end points.
 In the case of advanced life
support, however, thetherapeutic goals sometimes shift from
extending life toallowing life to end. Recent Canadian health
research hasshifted from matters of life-support administration
toissues in life-support discontinuation.
Concurrent with
this trend are qualitative investigations into end-of-lifedecision-making
and understanding the ICU as a socialworld,
as well as
calls to assess the ethical and socialinfluences of biomedical
However,biomedical, evaluative, ethical
and social science studiesof life-support technology remain
poorly integrated.
These combined disciplinary perspectives can be used toexamine
the diverse purposes of life-support technologiesas they are
used in practice. "Real" technological purposescan then be
addressed more explicitly in assessmentexercises.
objective of our study was to explorethe purposes for which
advanced life support is used in thecare of critically ill,
dying patients who are unable to maketheir own decisions.
The descriptive aim of the research, and the social natureof 
the subject matter, called for a qualitative, naturalisticapproach
to inquiry.
The study was conducted over 14months in the
15-bed closed ICU of St. Joseph's Hospital,Hamilton, Ont. In
1-week blocks 52 full-time nurses, 25part-time nurses and 7
intensivists attend the ICU; every2 months, 4 junior residents
rotate through the ICU.

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