Introduction
Most deaths in intensive care units (ICUs) take place after a decision is made to limit or withdraw medical treatment. Questions regarding the level and aim of treatment form an important part of day-to-day activities in ICUs [
1]. According to Norwegian legislation, healthcare decisions involving serious interventions should be based on informed consent [
2]. However, ICU patients generally have impaired cognition and are unable to decide for themselves; therefore, they depend on surrogates to make decisions on their behalf [
3]. Traditionally, and due to legislation, families in European countries have been less involved in end-of-life decisions than in the USA [
4‐
6]. In Norway, legislation gives the physicians in collaboration with other clinicians (physicians and nurses) the final decision-making authority [
2]. The Patients’ Rights Act (1, §4.6) states that, in order to determine patients’ wishes, if possible information shall be obtained from next of kin about the patient’s presumed consent [
2]. Involving family members as informants and spokespersons for the patient is a challenging process. To participate in the decision-making process, they need detailed information and thorough comprehension of the patient’s prognosis. Moreover, relatives do not always know the patient’s preferences and may have difficulty discriminating between the patient’s values and their own interests [
7,
8]. It may also be difficult for them to understand the complexity and severity of the condition in an emotionally demanding situation [
9]. Providing family members with appropriate information over time increases their ability to participate in the decision-making process [
1,
10‐
12].
A European consensus committee advocates a shared approach to end-of-life decisions, involving both the caregiver team and patient surrogates. The family’s role is to communicate the patient’s preferences [
7,
13]. However, according to Scandinavian studies, physicians consider limiting intensive care treatment to be a medical decision in which they are the principal arbiter [
14‐
16], and this often occurs without including nurses [
17,
18] or making ethical reflections explicit [
16]. Moreover, some physicians are reluctant to discuss ICU goals and methods with relatives when the patient is incompetent [
19]. Written advanced directives are not common [
19] and have no legal authority in Norway.
The aim of this study is to examine relatives’ experience of the end-of-life decision-making process in Norwegian ICUs. To what degree did they feel included? Did they receive necessary information? Were they asked about the patient’s preferences, and how did they see their role as a family member in the decision-making process?
Discussion
The major finding of this study is that the concept of “wait and see” describes the communication process with families in the participating Norwegian ICUs in various ways. Despite well-documented strategies to prepare families for end-of-life decisions [
22‐
24], the families’ perspectives in this study reveal an ineffective and ambiguous communication strategy. This is an area where the data can be interpreted in different ways. The end-of-life decision may seem sudden and unexpected because the family is not mentally prepared. We also know that being in an emotionally charged situation may reduce the family’s ability to recognize the physicians’ information [
22]. However, it can also be considered as an unclear communication process where the reality of the situation is played down.
Some uncertainty in the communication process can probably be related to an interpretation of current legislation on decision-making processes when the patient lacks decision-making capacity [
2]. The legislation gives no details as to how and when families should be included in decision-making. Written guidelines on intensive care ethics are not common in Scandinavia [
19]. However, a new Norwegian guideline for end-of-life decisions exists, but its implementation is still controversial among physicians, who may be reluctant to change established practice [
25]. Our results, nevertheless, show clearly that families experience the usual approach based on vague communication as inappropriate.
“Wait and see” might be a term that physicians use to delineate a period of time to ensure that the withdrawal decision is correct [
16,
26]. The process of defining a turning point where treatments are considered futile is ethically challenging [
17,
19]. However, the expression “wait and see” is itself elusive, and together with continued full treatment and vague communication, it obscures the severity of the situation, which the time limit is meant to signal [
13,
26]. Our study demonstrates that this often resulted in delayed communication with families about adjusting treatment goals, denying them the opportunity to communicate the patient’s preferences. Similarly to other studies, this study shows that families need regular meetings with physicians with an appropriate balance between hope for survival and accurate and straightforward information about the illness and the prognosis [
27,
28].
When physicians finally raise the end-of-life issue, they seem to have run out of time to include the family. Consistent with other Scandinavian research in this field, most participants in our study were merely told the decision [
29,
30]. Hence, they were left with unanswered questions and sometimes doubted the decision. They expected their contribution to the process to be important for the patient; on the other hand, some studies have questioned whether the family is able to communicate the patient’s “best interests” with regard to values and quality of life issues and, thereby, protect the patient’s autonomy [
7,
31,
32]. However, if the voice of the family is supposed to express the patient’s wishes, it is important that they be allowed to participate earlier in the decision-making process.
As reported in other studies, nurses seldom took part in end-of-life discussions or in family–physician conferences [
17,
33,
34]. Nurses and doctors are, therefore, not utilizing the waiting period properly in order to prepare the family for the final end-of-life decision. A few family members were satisfied with and (to some degree) included in the decision-making process (Fig.
1). The ICU period for these patients was limited to a few days. A possible interpretation is that the patient was expected to die soon at the time of admission to the ICU, and that communication efforts towards families were thus maximized. This first proactive step was laying the groundwork [
35] by establishing a relationship and providing the family with emotional support. The next step, as emphasized in other studies and guidelines [
22‐
24,
35,
36], introduced a clearer communication of the prognosis, allowing the family and the clinicians together to revise the initial goals [
37]. Nurses were included in the meetings to some degree and used their acquired relationship and knowledge to support the family after the meetings. Consistent with other studies, our results therefore suggest that nurses should engage more in end-of-life situations and contribute to building a team for family support [
13,
28,
38]. For these few families who experienced shared decision-making, the “wait-and-see” expression was understood as a fragile time in which they were able to prepare for the final decision to withdraw treatment.
This study is limited by the participants’ recollections of the decision-making experience. It is impossible to know if their recollections exactly describe their thoughts and feelings at the time of the decision. Although this qualitative methodology limits generalization, the findings still provide insight into the decision-making process as the families experienced it, and these insights may be transferable to ICUs other than those that participated in the study.
Acknowledgments
Profound gratitude is extended to the participating ICUs, to the participants, and to all colleagues who have read, discussed, and commented during the research process. This work was funded by Northern Norway Regional Health Authority, University Hospital of Northern Norway, The Norwegian Nurses Organization, and The Research Council of Norway.