The purpose of this article is to propose that collaboration is a valuable way to address ethical issues associated with the treatment of elderly patients near the end of life in intensive care units (ICUs). Collaboration among health care providers and with patients and their families has been called "an ethical responsibility of the highest priority" (Levine, 1989, p. 5). This responsibility is particularly critical in intensive care units (ICUs) and in making decisions associated with the end of life.
ELDERLY PATIENTS IN INTENSIVE CARE UNITS
The term ICU may not evoke an image of elderly patients, but there are many older adults who are part of the daily census in ICUs. In combined data from nine large ICU studies, the mean age for patients was older than 65 (N = 121,101) (Baggs, 1999). The number of elderly patients in ICUs can be expected to increase, both because of increasing numbers of older members in our society, and because increasing illness is associated with aging. With the aging of the baby boom generation, the total number of individuals ages 65 and older is expected to reach 70.2 million, or 20.1% of the population of the United States, by 2030 (Cornman, 1997; U.S. Census Bureau, 1999). Care in ICUs is, in large part, care for geriatric patients. Elderly patients in the ICU have special needs and present ethical dilemmas.
A number of issues that might distinguish elderly patients needing life sustaining technologies, and thus who might be ICU patients, have been identified (Office of Technology Assessment [OTA], 1987). Compared to younger patients, elderly individuals are at greater risk of critical illness; have more chronic comorbidities (which may mean poorer baseline status even before a critical illness or surgery), and have an increased likelihood of dementing illnesses. Elderly individuals are also at risk because of a lack of training of health professionals to care for seriously ill elderly individuals (OTA, 1987). The Health needs of the aging cohort, in combination with technological advances and the ability to support failing organ systems for prolonged periods, have resulted in rapid growth in the use of ICUs. The related issues of escalation of health care costs and continuing growth of the aging population create an urgent need for health policy planners to address the use of high technology for seriously ill aging patients. Frank discussions are needed about later life health care decision-making among patients, their families, nurses, physicians, and other health care professionals.
DECISION-MAKING AND LIMITING CARE BASED ON AGE
Effect of Age on ICU Care
Fulmer and Walker (1992) noted "an unspoken bias that the elderly patient in an intensive care unit is '!ess viable*" (p. 8). There are a number of studies demonstrating differences in the treatment decisions related to elderly patients in acute care - generally in the direction of a lower level of treatment. When seriously ill, elderly patients are less likely than younger patients to have invasive procedures (Harael et al., 1996), to be hospitalized in teaching hospitals (Peris & Wood, 1996), to be admitted to an ICU (Hanson & Danis, 1991), to receive life-sustaining treatments if they are admitted to an ICU (Castillo- Lorente, RiveraFernandez, & Vazquez-Mata, 1997; Hamel et al., 1999), and more likely to have do-not-resuscitate (DNR) orders (Boyd, Teres, Rapoport, & Lemeshow, 1996; Wengeretal., 1995).
Another indication of a less intense level of treatment provided to elderly individuals is the lower charges per acute care hospital admission for elderly patients than for younger patients, despite longer lengths of stay (Hamel et al., 1996.
Peris & Wood, 1996). This is true despite the finding that advanced age alone generally is not a predictor of negative ICU outcome (Chelluri, Grenvik, & Silverman, 1995; Chelluri, Pinsky, Donahoe, & Grenvik, 1993; Kass, Castriotta, & Malakoff, 1992; Kleinpell & Ferrans, 1998; Rady, Ryan, Si Starr, 1998; Seneff, Wagner, Wagner, Zimmerman, & Knaus, 1995).
The reasons for these differences in treatment are more difficult to assess. Choices by patients and providers may be based on age. Older patients may choose to receive less care. A higher preference for DNR orders has been associated with age (Phillips et al-, 1996). On the other hand, in an ICU study there was no relationship between DNR preferences and age (Elpern, Patterson, Gloskey, & Bone, 1992). Preferential allocation of services to younger patients does not appear to be driven by differences in patients* desire for lifeextending treatment or severity of illness (Hamel et al. 1 996). Providers, consciously or not, may limit treatment simply because patients are older (Adams, Jamieson, Rawles, Trent, & Jennings, 1995; King et al., 1998).
Limitations may be made by providers, again consciously or not, based on gender (Baggs, 1999), as age and gender are almost inextricably linked. As the population ages, the ratio between numbers of men and women shifts toward more women. Jecker (1991) has examined risks to women of age-based rationing.
Although the authors are aware of no formal governmental or institutional policies at present for limiting intensive care for elderly individuals, some investigators have suggested that covert rationing exists in the form of a bias against admitting elderly patients to an ICU or limiting their treatments after they have been admitted (Chelluri et al., 1995; Hamel et al., 1996; Hamel et al., 1999). Chelluri et al. (1995)- hypothesized that because elderly patients have more comorbidities, they may not be offered ICU admission due to a perception that their outcome is poor relative to that of younger patients. Stillman, Braítman, and Grant (1998) found when physicians considered clinical vignettes for a critically ill 85-year-old patient versus a 50-year-old patient, age alone had little effect, but its effect in leading to decisions for less aggressive treatments was magnified by comorbidities.
Among a cohort of 9,105 hospitalized patients (median age 63 years, 44% women), Hamel et al. (1999) found that although older patients less often wanted aggressive treatments than younger patients, physicians often underestimated older patients' preferences for life-extending care. Older age was associated with higher rates of physicians' decisions to withhold ventilator support, surgery, and dialysis (Hamel et al., 1999). Preferential allocation of services to younger patients occurred despite controlling for differences in patients* severity of illness, functional status, and preferences for life-extending treatment.
ETHICAL ISSUES FOR ELDERLY PATIENTS IN THE ICU
One group of physician authors identified four major relevant ethical dilemmas (Clarke, Goldstein, & Raffin, 1994):
* Use of ICUs for elderly individuals.
* Age differences in success rates for cardiopuimonary resuscitation (CPR).
* Use of DNR orders.
* Ways to optimize communication between physicians and patients.
They summarized research findings related to success of CPR for elderly individuals, noting that the results have been mixed, and that factors other than age have been more reliable indicators of whether CPR will be successful or not. They supported discussions of DNR and CPR with patients including realistic assessments of potential benefits and burdens. For communication improvement, Clarke et al. (1994) strongly supported discussions of advance directives, beginning with routine office visits, and having ICU discussions about the end of life in quiet, nonchaotic areas - not in ICU rooms or hospital corridors.
Nurses, too, have identified ethical issues related to their care of elderly patients in the ICU (Strumpf & Paier, 1992). Nurses in ICUs who were interviewed believed there were differences between medical and nursing perspectives, with nurses believing that physicians often continued treatments when the treatment had little potential to improve quality of life. Nurses saw themselves as the coordinators of care who had the position of identifying when an ethics consultation was needed and either getting a consultation or encouraging families to make a request. They believed elderly patients often did not understand the implications of treatment decisions. Nurses also identified issues for families of elderly patients in ICUs - including unrealistic expectations, lack of agreement among family members, and decisions that did not seem in the patients* best interests. The nurses believed their voices should be heard in physician, patient, and family discussions about end-of-life decision-making.
There is potential for collaboration among health care professionals if they focus on the patient and issues related to high quality appropriate care. The nursing voice is important in this decision-making, and communication about how best to care for patients is likely to be effective in promoting that collaboration.
PROBLEMS IN END-OF-LIFE DECISION-MAKING IN THE ICU
There are other, more general, problems in the ICU related to endof-life decisions also applying to elderly individuals. With many possibilities available for treatments, decisions must be made about which treatments are physiologically appropriate and valuable in terms of patient goals and preferences. There is evidence that both health care professionals and members of the public (who are potential patients and family members) are concerned about the provision of treatments that are not beneficial, and are intrusive and unwanted (American Health Care Decisions, 1997; Baggs & Schmitt, 1995; Solomon et al., 1993). At the same time, members of the public are concerned that providers may decide to withdraw treatment before patients or family members have agreed to withdrawal (American Health Care Decisions, 1997). There are other problems, all of which tend to diminish patient participation in decision-making. These include (Baggs & Schmitt, in press):
* Physician dominance of end-oflife decision-making without consideration of patient and family wishes.
* Failure to initiate discussions about end-of-life decision-making until patients no longer have capacity for involvement.
* Confusion about what comfort care entails and failure to provide it.
* Failure to include nurses and other non-physician providers in discussions.
* Consequent failure to gather information other providers may have regarding patient wishes.
Collaboration among providers and with patients and families provides a way to address some of these problems. It is not the answer, but an answer.
SUPPORT FOR COLLABORATION IN CARE AND DECISION-MAKING
Collaboration among health care professionals and with patients and their families is important in managing end-of-life decision-making for all patients in ICUs, but it is especially important for elderly individuals. Collaboration between nurses and physicians has been defined as physicians and nurses working together, sharing responsibility for solving problems, and making decisions to formulate and execute plans for patient care (Baggs Si Schmitt, 1988).
Empirical Support for Collaboration
There is empirical support for collaboration among health care providers in patient care delivery, including several studies from settings where many of the patients are elderly, and other studies from ICU settings. In early quasi -experimental work conducted at a long-term care facility, Feiger and Schmitt (1979) studied diabetic patients randomly assigned to interdisciplinary team care or usual care. The team care resulted in less decline in functional status and physiological, physical, social, and emotional health outcomes, and more positive change. The rank order of teams in collegiality was the same as their rank order of success in patient outcomes.
Another study conducted with geriatric patients occurred at a Veterans' Administration hospital (Rubenstein et al., 1984). A geriatric evaluation unit (GEU) for inpatient care was established with an interdisciplinary team form of care. The researchers compared frail elderly patients randomly assigned to the GEU or regular acute care floors. The GEU patients had lower mortality, fewer acute care days, fewer nursing home placements, fewer nursing home days, fewer hospital réadmissions, improved functional status and morale, and lower 12-month direct costs for institutional care than the usual care patients.
Collaboration between ICU physician and nurse care providers has been supported by a number of studies. Knaus et al. studied 13 ICUs across the United States and concluded that staff interaction and coordination, a variable very similar to collaboration, was critical in accounting for differences in mortality across units (Knaus, Draper, Wagner, Si Zimmerman, 1986). In a later, more complex study, an expanded group of researchers studied 42 ICUs and found that a positive association of caregiver interaction including communication, coordination, and other interactional variables led to better ICU care and shorter risk-adjusted length of stay for patients (Shortell et al., 1994; Zimmerman et al., 1993). Mitchell, Armstrong, Simpson, and Lentz (1989) described an existing ICU exemplifying five key elements of excellence, including physician-nurse collaboration, and found a lower than predicted mortality. In two other studies, Baggs et al. have found that medical ICU (MICU) nurses' reports of more collaboration between nurses and physicians in making the decision to transfer patients from the ICU to a general unit predicted better patient outcomes of fewer deaths and MICU réadmissions (Baggs, Ryan, Phelps, Richeson, Sc Johnson, 1992; Baggs et al., 1999).
Ethical Support for Collaboration
In addition to the empirical support for collaboration between nurses and physicians, there is strong conceptual and ethical support for the inclusion of patients and families in decision-making. The ethical principle of autonomy, which has become so valued in recent years, supports patients as the primary decision-makers in their own health care. It also supports the inclusion of others who may lend the patient support in that decision-making or provide the best substituted judgment when the patient is unable to participate. These others certainly include family members and may include members of the health care team in addition to physicians (e.g., nurses, social workers). The newer emphasis on relational or caring ethics also would support working with patients, families, and whomever is identified as helpful in decisi on -making. Evidence shows that patients are more likely to discuss end-of-life care with their families than with their physicians and they prefer family members to have the decisionmaking authority (Hiñes et al., 1999). Cicirelli (1997) found that older participants were more positive in relation to depending on others to help with, or in some cases to take over, end-of-life decision-making. Nurses often view their role in deliberations as providing support for patient and family viewpoints. These findings make inclusive collaboration particularly vital in the care of elderly ICU patients.
Collaboration to Improve End-ofLife Decision-Making
Both nurses and physicians have written about the importance of collaboration in making bioethical decisions (Baggs, 1993; Luce, 1990). Collaboration allows input from differing perspectives - increasing the amount of information available clinically and in regard to values being considered. According to Baggs (1993):
With collaboration there is sharing of information and perspectives, respect for patient and family autonomy, and disclosure (p. 111).
An ethical model for improving end-of-life decision-making would include involvement of the patient, the family or significant others, and all health care providers involved with the patient. Steps would be taken to reach consensus about preferred treatment, information would be shared, communication would be open, and the patient's primacy would be respected (Baggs & Schmitt, in press; Charles, Gafni, & Whelan, 1997; Dowdy, Robertson, & Bander, 1998).
Clarke et al. (1994) recommended advance directives to improve ICU patient-physician communication. It is noteworthy that Clarke et al. (1994) (authors are physicians) made no mention of how health care providers other than physicians might be important in the decisionmaking process. Shidler (1998) has written recently of her ethnographic study of end-of-life decision-making for elderly residents in a long-term facility in Quebec. She found treatment decisions were facilitated by communications among everyone involved with the patient, including family members, physicians, nurses, aides, and housekeepers.
Some concrete suggestions for improving the decision-making process have been gathered from family members whose loved ones have died in ICUs or acute care hospitals. These recommendations include (Jacob, 1998; Tilden, Tolle, Garland, & Nelson, 1995):
* Encouragement of advanced planning.
* Timely communications.
* Clarifications of families' roles in decision-making.
* Facilitating family consensus.
* Emotionally supporting family decisions.
* Providing access to patients before and after death.
* Accommodating family grief. Behaviors that were not helpful included:
* Rigid adherence to standardized routines without awareness of how it created problems for families.
* Lack of expressions of human caring and personal attention.
* Lack of information.
COLLABORATIVE ETHICAL DECISION-MAKING AT THE END OF LIFE: CLINICAL IMPLICATIONS FOR INTENSIVE CARE NURSES
* Appearance of detachment (Pierce, 1999).
* Postponing discussions about treatment withdrawal.
* Delaying withdrawal after it was scheduled.
* Placing the full burden of decision-making on one person.
* Withdrawing from the family.
* Defining death as a failure (Tilden et ai., 1995).
Jacob (1998) found that families wanted to work with caregivers in a collaborative interaction, and the family's long-term ability to cope with their grief was influenced by how well that interaction worked.
It is clear that the most important aspects of end-of-life decision-making for elderly patients in the ICU involve personal attention to patients and families, solicitation of information from multiple providers and others involved with the patient, listening, and attending to people. The Table presents clinical implications related to collaborative ethical decision-making for elderly patients in ICUs at the end of life.
Elderly patients commonly are admitted to ICUs, and they are at higher risk for critical illness than younger patients because of comorbidities and because care providers may not be well prepared for seriously ill elderly patients. There is evidence of differences in treatment of elderly patients, perhaps appropriately and perhaps not, but the differences mean providers should assess patients based on individual conditions rather than treating elderly individuals categorically. This and other ethical issues for elderly patients who are ill and have life threatening conditions can be addressed best by collaboration among providers and with patients and families. Collaboration enables providers, patients, and families to have more information for decisionmaking. Collaboration is supported ethically as a way to clarify and treat patients according to their own wishes or as a way to approximate what they would have chosen on their own.
Interdisciplinary collaboration plays an important role in ICUs where professionals must provide competent physical care using complex technologies. To meet the needs of patients in an ethical, caring, and compassionate manner, professionals also must collaborate and work together with patients and families.
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COLLABORATIVE ETHICAL DECISION-MAKING AT THE END OF LIFE: CLINICAL IMPLICATIONS FOR INTENSIVE CARE NURSES