An Exploratory Investigation into the Roles of Critical Care Response Teams in End-of-Life Care

Table 1

Participant remarks.

Statement	Participant	Quotation
A	PHYS03	“...we have a tremendous degree of wisdom between us that’s very helpful and I think that may be why we can make decisions [...] because we’ve got a group of people.”
B	PHYS02	“You’re asking a resident to go out and see somebody who probably presumably doesn’t have the same experience or knowledge as staff physician does, hasn’t been in the scenario as often and so to start talking about end of life stuff, you have to be fairly confident that you understand what’s going on with the patients and truly, you know, there’s not something that you can do to make it all better. And you also have to be comfortable with talking about end of life stuff.”
C	RN	“Residents who are insecure about making decisions and we come and as a team we say, you know, this is not appropriate care. It’s not appropriate to be putting this person on a ventilator and prolonging their death. It’s not going to enhance their life in any way, and then we facilitate the resident getting to that point, maybe helping set up.”
D	PHYS06	“the people on the RACE team have a better understanding or appreciation, I guess, of when a patient looks like they’re at end of life or in specific patients, do we think that they’re actually... that we could actually fix them with invasive measure in the ICU and give them a reasonable outcome. I think we have a bit more or often a lot more baseline knowledge of that than initial providing services.”
E	PHYS04	“We’ve had these discussions many, many, many times. We also have seen so many patients that we know which, you know, who of these patients have a chance of surviving and who doesn’t, [...] we can anticipate what’s going to happen. And I think that plays a very important part of the discussion you can have with the family.”
F	PHYS04	“... families often feel more reassured when the actual provider of critical care says critical care is not appropriate in this situation. That it comes better from the word of mouth of the person who’s actually offering or providing the treatment rather than the providing service.”
G	RN	“I have to say though, since the beginning of RACE, I think there’s been a lot more dignity in death than there was before RACE started. I think we’ve avoided a lot of admissions to ICU because of RACE. I think we have done a lot of end of life at the bedside.”
H	PHYS03	“I think I felt very strongly that it was a very important facet of RACE but I often felt that I was not the appropriate person to be doing that and that... that we had been forced into a situation in which we’re making the decision because the staff doctors had either not broached the situation adequately or had not appreciated the situation and the severity of the illness [...]”
	RN	“they called us into the room, and we have to have an end of life discussion with a family that we’ve never seen before. We have no rapport with them. It happens time and time again. And it’s inappropriate in that regard, I mean, certainly when it’s acute, or the patient’s new, it’s at least acceptable and we’re better at it than a lot of people, but it seems like a lot of services don’t accept that fact that people die.”
I	PHYS05	“I’ve gone to see a patient where I’m not sure that there’s much that we can offer but then you speak to the attending service and find out that the baseline is quite a bit different than what your expectation was[...]. And we, ourselves, even when it comes to end of life care, we can’t be so drawn into our own opinions that we’re closed to other people’s [...] I’ve changed my goals based on what other physicians who know patients better...the patient better than I do. So, I do worry about RACE and in that regard because we’re the cavalry coming in and giving an opinion on the patient we don’t necessarily know as well as the attending team.”
J	PHYS05	“I think some people are just uncomfortable telling it like it is and just being honest when they know that there are options that can temporize but not necessarily treat. And there’s a big difference between survival and recovery for patients. [...] Sometimes I think the attending services are worried about consulting palliative care right off the bat so it almost seems like, “let’s get RACE to see, see if there’s anything we can do. If there’s nothing we can do then the palliative care comes in [...] So where I think that there’s lots of times when the answer is no, it’s just they’re afraid to say it or there’s some barrier to that and having the discussions. [...] it’s a comfort thing.”
K	PHYS01	“I think that somebody’s got to do it and we have a good perspective to do it in terms of like expertise, the problem is that we don’t have the relationships. So, from a relationship point of view, it’d be best to have the family doc or the primary treating service in the hospital. But usually those two groups don’t have very much expertise in knowing who’s a good candidate and who’s not. They don’t have the experience in having discussions either. [...]I’ve always felt that that was one of our roles because the alternative is much much worse. So we may not be the perfect person to do it but if we don’t do it, nobody does it. Then you’ll end up with a lot of people who shouldn’t come to the ICU ending up in the ICU.”
	RT	“But do I think personally that we should get involved with all end of life discussions? Absolutely not. I agree with palliative care. Absolutely. That’s their bread and butter even more than critical care. I think they should be involved more. but if we’re already involved, we’re involved. We’re there. We’re not going to neglect a patient. Never ever.”
L	PHYS05	“...sometimes we’ve had patients in the ICU who are there for three months. You discuss. You get to know them well. You write your opinion. It’s all written down. And then a junior resident in the middle of the night gets called and changes goals of care with no understanding whatsoever of what that means.”
	RN	“It can be a lot more stressful being on at night. It’s okay if you have a resident that’s open to ideas. But when you have a resident that thinks they know it all and, you know, doesn’t want to listen, you know, not open to things, doesn’t want to call their senior to... that can be quite frustrating.”
M	PHYS02	“Other fascinating thing that’s come up a few times is patients come in and somebody has taken the time to have an end of life discussion with them and you can’t find them. So, it might be on the chart written in [a] progress note and the... you may stumble upon it, you may not stumble upon it. But in our Oacis system there should be a way of flagging a document that discussion has been had..”
N	RT	“I’ve often said this to residents, is, “You know, you can’t just say, we’re going to help them. Do you want us to help your family member?” Because everyone is going to say yes, we do. But if you say, you know, we’re going to put them on life support, they may never come off life support. This is going to be a very uncomfortable tube for them to have put in their throats. They will not be able to talk to you or eat. When you start saying those words, then suddenly family, oh wait a minute, no they wouldn’t want this. No, no, no.”
O	RN	“...families are more receptive to understanding that, you know, yeah everyone dies in the end and we could help make it a comfortable transition. Of course, you’ll have your, you know, couple percent that still want everything but most people become receptive if you have someone that can explain it properly.”
P	PHYS02	“So as everyone learns in medicine, that you tell patients something that doesn’t sound good, most of what they retain is very limited. And so even though we thought we had a conversation where we thought we expressed ourselves very well, it may not have been understood to the same degree. So, you know, the doctor and patient go separate directions with a different, completely different idea of what that conversation was just about. I think that happens an awful lot.”