Jacob A Blythe1, Nancy Kentish-Barnes2, Anne-Sophie Debue3, Daniel Dohan4, Elie Azoulay5, Ken Covinsky6, Thea Matthews4, J Randall Curtis7, Elizabeth Dzeng8. 1. Stanford University School of Medicine (J.A.B.), Stanford, California, USA. 2. Assistance Publique Hôpitaux de Paris (APHP) (N.K.-B.), Hôpital Saint Louis, Famiréa Research Group, Paris, France. 3. Assistance Publique Hôpitaux de Paris (APHP) (A.-S.D.), Hôpitaux Universitaires Paris Centre (HUPC), Hôpital Cochin, Medical Intensive Care Unit, Paris, France; UVSQ, INSERM, Équipe Recherches en éthique et épistémologie (A.-S.D.), CESP, Université Paris-Saclay, Paris, France. 4. Philip R. Lee Institute of Health Policy Studies (D.D., T.M., E.D.), University of California, San Francisco, California, USA. 5. Médecine Intensive et Réanimation (E.A.), Hôpital Saint-Louis, APHP, Paris, France; Université de Paris (E.A), Paris, France. 6. University of California (K.C.), San Francisco, California, USA. 7. Division of Pulmonary (R.C.), Department of Medicine, Division of Geriatrics, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.C.), University of Washington, Seattle, Washington, USA. 8. Philip R. Lee Institute of Health Policy Studies (D.D., T.M., E.D.), University of California, San Francisco, California, USA; Division of Hospital Medicine (E.D.), Department of Medicine, University of California, San Francisco, California, USA. Electronic address: liz.dzeng@ucsf.edu.
Abstract
CONTEXT: The provision of potentially non-beneficial life-sustaining treatments (LSTs) remains a challenging problem. In 2005, legislation in France established an interprofessional process by which non-beneficial LSTs could be withheld or withdrawn, permitting exploration of the effects of such a legally-protected process and its implementation. OBJECTIVES: To characterize intensive care unit (ICU) interprofessional team decision-making and consensus-building practices regarding withholding and withdrawing of LSTs in two Parisian hospitals and to explore physician and nurse perceptions of and experiences with these practices. METHODS: This was an exploratory qualitative study utilizing thematic analysis of semi-structured, in-depth interviews of physicians and nurses purposively sampled based on level of training and experience from two hospitals in Paris, France. RESULTS: A total of 25 participants were interviewed. Participants reported that the two Parisian hospitals in this study have each created an interprofessional process for withholding or withdrawing non-beneficial LSTs, providing insight into how norms of decision-making respond to systems-level legal changes. Participants reported that these processes tended to be consistent across several domains: maintaining unified messaging with patients, empowering nurses to participate in end-of-life decision-making, reducing moral distress provoked by end-of-life decisions, and shaping the ethical milieu within which end-of-life decision-making takes place. CONCLUSIONS: The architecture of the interprofessional process created at two Parisian hospitals and its perceived benefits may be useful to clinicians and policy-makers attempting to establish processes, policies, or legislation directed at withholding or withdrawing potentially non-beneficial LSTs in the United States and elsewhere.
CONTEXT: The provision of potentially non-beneficial life-sustaining treatments (LSTs) remains a challenging problem. In 2005, legislation in France established an interprofessional process by which non-beneficial LSTs could be withheld or withdrawn, permitting exploration of the effects of such a legally-protected process and its implementation. OBJECTIVES: To characterize intensive care unit (ICU) interprofessional team decision-making and consensus-building practices regarding withholding and withdrawing of LSTs in two Parisian hospitals and to explore physician and nurse perceptions of and experiences with these practices. METHODS: This was an exploratory qualitative study utilizing thematic analysis of semi-structured, in-depth interviews of physicians and nurses purposively sampled based on level of training and experience from two hospitals in Paris, France. RESULTS: A total of 25 participants were interviewed. Participants reported that the two Parisian hospitals in this study have each created an interprofessional process for withholding or withdrawing non-beneficial LSTs, providing insight into how norms of decision-making respond to systems-level legal changes. Participants reported that these processes tended to be consistent across several domains: maintaining unified messaging with patients, empowering nurses to participate in end-of-life decision-making, reducing moral distress provoked by end-of-life decisions, and shaping the ethical milieu within which end-of-life decision-making takes place. CONCLUSIONS: The architecture of the interprofessional process created at two Parisian hospitals and its perceived benefits may be useful to clinicians and policy-makers attempting to establish processes, policies, or legislation directed at withholding or withdrawing potentially non-beneficial LSTs in the United States and elsewhere.