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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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08/05/2014

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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 
 
B
ackground:
 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withheld, provided,continued or withdrawn in the ICU.
 
Methods:
 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 
 
 
2
 
data, multidisciplinary team consensus,
 
sharing of resultswith participants and theory triangulation.
 
esults:
 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.
 
Conclusions:
 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
 
illness.
1
 
 
 
3
 
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.
2
 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.
3-7
Concurrent with
 
this trend are qualitative investigations into end-of-lifedecision-making
8-10
and understanding the ICU as a socialworld,
11,12
as well as
 
calls to assess the ethical and socialinfluences of biomedical
 
technologies.
13,14
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.
15,16
The
 
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.
 
Methods
The descriptive aim of the research, and the social natureof 
 
the subject matter, called for a qualitative, naturalisticapproach
 
to inquiry.
17
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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