Abstract
BACKGROUND: The act of withdrawing advanced life-sustaining therapies, more specifically mechanical ventilation, is performed in hospitals all over the world. Success involves coordination of several members of the patient care team, including nurses, providers (physicians nurse practitioners, or physician assistants), and respiratory therapists (RTs). The experiences of RTs surrounding this procedure are not well documented. The aim of this study was to explore the lived experience of RTs who have participated in withdrawal of advanced life-sustaining therapies, utilizing a hermeneutical phenomenological approach.
METHODS: Individual interviews were conducted with experienced RTs that were audio recorded and transcribed. The data were analyzed by 4 health professionals, and data were triangulated.
RESULTS: Three themes emerged from the study: (1) impact of power relations surrounding the process, (2) needing tools to provide quality withdrawal of advanced life-sustaining therapies, and (3) emotional involvement/exposure. It was clear from the analysis that RTs desire more education, to be part of the decision-making, and to be appreciated for their role in this emotional process.
CONCLUSIONS: Through this study, the role of RT in withdrawal of advanced life-sustaining therapies is better understood, which can only lead to improvement in the overall process for health care team, patient, and families.
- withdrawal of advanced life-sustaining therapies
- palliative extubation
- respiratory therapist
- mechanical ventilation withdrawal
- end of life
- terminal care
- phenomenology
Introduction
Cessation of mechanical ventilation is one of the most pronounced and frequent aspects of withdrawing advanced life support or life-sustaining therapies.1,2 One in five Americans die in ICUs each year, and close to half of these deaths are related to withdrawal of aggressive care or advanced life-sustaining therapies.3-5 Withdrawal of advanced life-sustaining therapies, more specifically withdrawal of mechanical ventilation, involves the discontinuation of mechanical respiratory support, delivered via an endotracheal or tracheostomy tube, from a patient anticipated to expire relatively soon thereafter removal. Withdrawal of advanced life-sustaining therapies is a shared decision among family, loved ones, and caregivers to allow a natural death by disconnecting a life-sustaining treatment: a mechanical ventilator.6,7
The goal of withdrawal of advanced life-sustaining therapies is to offer the patient and family a more natural, intimate, and comfortable dying process/experience.2 Integral to this are respiratory therapists (RTs) who are the primary managers of mechanical ventilators and the clinicians expected to perform the extubation, typically with nurse presence, at times in the absence of a physician, as was the case with this study site.8,9 In some institutions, including this study site, RTs are often excluded from shared decision-making or discussions surrounding withdrawal of advanced life-sustaining therapies, despite their expertise and direct caregiving relationship with patients.10-12 The process of withdrawal of life-sustaining therapies occurs after in-depth discussions between the medical team and family and may be perceived as a distressing role expectation for the RT.10 There is ample research evaluating physician’s and registered nurse’s (RN) practices and responses to end-of-life (EOL) care,8,10-16 yet there is a paucity of literature concerning the experiences of RTs despite their vital role in delivering EOL care, particularly compassionate extubation. One study with RTs showed their perspectives on withdrawal of life-sustaining therapies differ from those of RNs regarding explanation of the process, availability of the physician, and peacefulness and privacy of the process.15 Furthermore, like RNs, RTs expressed a desire for a role in the decision-making process, more explicit orders for the process of terminal extubation, and incorporation of education related to EOL in their training.10,15,16
The purpose of this study was to contribute to the body of knowledge of this understudied population by utilizing a rigorous qualitative methodology and uncover new knowledge that could help inform current medical, respiratory, and nursing practice. The research questions this study sought to answer from RTs at a single site ICU: Research question 1: What is the lived experience of hospital RTs when withdrawing advanced life-sustaining therapies at EOL employing a phenomenological approach? Research question 2: What is the meaning and experience of withdrawing advanced life-sustaining therapies from the perspective of hospital RTs?
QUICK LOOK
Current Knowledge
Withdrawal of advanced life-sustaining therapies, or withdrawal of mechanical respiratory support, is a shared decision between the patient, family, and health care team. Respiratory therapists (RTs) are important members of health care team and essential for the extubation process.
What This Paper Contributes to Our Knowledge
RTs involved in end of life (EOL) care often feel overlooked with respect to EOL discussions prior to withdraw of care. RTs express the desire to be involved earlier and participate in discussions and failure to include them results in a feeling of disempowerment and job dis-satisfaction. Resolution if this issue requires a collaborative practice model with other providers.
Methods
This study utilized a hermeneutical phenomenological approach to gain insight and help to understand the essential essence of withdrawal of advanced life-sustaining therapies from the perspective of an RT. A hermeneutic phenomenological approach holds the belief that a real understanding of a phenomenon may be achieved by actively engaging in it. A person’s presence in the world, as well as relationship to the world, is paramount to interpretive phenomenological inquiry.17 The researchers’ presuppositions, or expertise and personal experiences related to phenomena under study, are assessed and valued as aspect of the analysis. Rather than a simple description of a lived experience in which the researcher brackets his or her own previous experiences and knowledge, the authors were aware of preexisting biases and interpreted findings within their own understanding, working to not just describe but interpret participants’ experiences.
Participants
Approval for this study was obtained from the hospital’s internal review board. The sample (N = 8) was recruited from a respiratory therapy department at an academic tertiary hospital in the southwestern United States that, at time of the study, employed fewer than 40 RTs. Recruitment was via direct e-mail from department head with a flyer and announcements at monthly staff meetings. Purposive sampling was used to recruit RTs of all gender with varying years’ experience in critical care, experienced with withdrawal of advanced life-sustaining therapies, and currently working in an adult medical-surgical, non-trauma ICU setting. Signed consent, including permission for audio recording, was obtained. Their right to stop the interview at any time along with employee emotional supportive services offered were reviewed. Names of participants were kept confidential from respiratory department leadership, and all recordings and transcriptions were de-identified. The research team had no line authority over participant pool or input into their evaluations. Participants were recruited then interviewed over a period of 4 months, until data saturation was achieved, or no new additional data were emerging from interviews.17 The small sample size was not surprising given the scope of this research was limited to one phenomenon encountered by RTs; purposive sampling occurred to target RTs with specific experience; participants were considered good informants, and interview data were rich.
Data Collection
Semi-structured, 1-h interviews were conducted prior to the COVID pandemic, audio recorded, then transcribed verbatim by an RT not otherwise associated with the study. Open-ended questions were employed in combination with probes, such as verbal and non-verbal cues (ie, head nodding and pauses in dialogue) to clarify responses. The overarching interview question was “What has it been like for you to withdraw mechanical ventilation for patients at EOL?” The interviewer then affirmed statements made and asked, “Can you tell me more about what made you feel that way?” If the participant described only one dimension or extreme of emotion, the interviewer then asked if the opposite emotion had ever been experienced and, if yes, to elaborate further.
Data Analysis
This study used Colaizzi’s18 7-step process for phenomenological data analysis (Table 1).18 Hermeneutic phenomenological analysis purports that the meaning at which researchers arrive is an amalgamation of meaning expressed regarding the phenomena by participants and researchers.19
Colaizzi’s Seven-Step Process for Phenomenological Data Analysis18
The transcription of raw data was subjected to phenomenological analysis with intensive and multiple readings of transcribed text. Significant statements were extricated from transcribed interviews to form essential themes of respondents’ answers. The themes were inductively examined for more universal and differing meaning of the phenomena. This was an iterative process with many referrals back to the original data for corroboration.
In addition, some of Guba and Lincoln’s20 quality enhan-cement strategies were employed throughout this inquiry to enhance the trustworthiness of findings.21 In short, Guba and Lincoln’s 4 strategies, credibility, transferability, dependability, and confirmability, are used to confer that findings are truthful, transferable, replicable, and representative of respondents instead of researchers, respectively.21 Three of these strategies were used. The first, credibility, the confidence in the truthfulness of participants and reported data, and authenticity, which emerges with conveyance of participant’s emotions within the lived experience, were achieved with (1) reflexivity on the part of all researchers involved and reflexive journaling maintained by the principal investigator (CAM) and (2) audio recording and verbatim transcription by an experienced RT not involved in the analysis.21 Reflexivity was achieved by exploring and journaling a priori assumptions and experiences regarding the phenomena. Next, confirmability, the objectivity of and between all researchers, and credibility were supported by having an RT (ERC) as a coinvestigator involved in all aspects of the research process.21 Initial findings were shared with all participants, reiterating power of member checking for truthfulness of findings to ensure validity of findings. Confirmation that researchers analyzed transcripts without misrepresenting intent of participants was given by 3 of the 8 participants who responded to the member-checking request. To enhance confirmability and dependability of findings, investigator triangulation was done following original analysis by 2 additional RN researchers (CAM, KJR) with extensive knowledge of the methodology.
Results
Participants were primarily female (62%) and between ages 31–50 y (75%). Mean years as an RT was 7.25 with a range of 2–13 y. All participants reported working in a hospital setting for their entire respiratory therapy career. Seventy-one percent reported receiving no EOL education as part of their RT education. Half (50%) reported receiving some palliative care education at some point in their career. Most participants (88%) reported experiencing the death of a loved one. At time of this study, RTs were not routinely part of EOL or palliative care education at the study site, and debriefings following stressful events were emerging. There was a nascent palliative care team primarily focused in the out-patient setting, not the ICU. Family-centered rounds were not practiced at the time of data collection, and, as is often the case, RTs were not always available during morning rounds with the interdisciplinary team due to patient workload and need for their presence elsewhere.
Three major themes emerged from the analysis of participants’ descriptions of their lived experience of withdrawing advanced life-sustaining therapies in the ICU setting: (1) the impact of power relations surrounding the process, (2) needing tools to provide quality withdrawal of advanced life-sustaining therapies, and (3) emotional involvement/exposure. Principal exemplars of these themes are provided below.
Theme 1: The Impact of Power Relations Surrounding the Process
An overarching theme of power relations surrounding withdrawal of advanced life-sustaining therapies process pervaded much of the data. Findings from this study illustrate the impact of power relations enveloping this process for RTs. Within this overarching theme were 3 subthemes, which demonstrate RTs’ lack of involvement with planning of withdrawal of advanced life-sustaining therapies, lack of appreciation for their role as a member of that team, and lack of opportunity for RT voices to be heard.
Subtheme 1A: Underappreciating Withdrawal of Advanced Life-Sustaining Therapies Process and Dying Process.
The first subtheme was related to a sense of RTs being underappreciated as people and professionals, and their role in withdrawal of advanced life-sustaining therapies taken for granted. Participants spoke about there being a lack of sensitivity for the dying process from other professionals as well as their own colleagues. “We look at it as points in a work load… right now it’s kind of a task.” Most participants reported RNs and physicians often considered withdrawal process a mere “task,” “it’s just a flip of the trigger,” rather than a process requiring sensitivity, vulnerability, and coordination. “… we’re always told at the last minute about what’s going to take place, as if it’s just a flip of the trigger and a lot of times it is just a flipping of a button, but it’s a person that’s flipping the button.” It was the perception of many RTs involved in withdrawal of advanced life-sustaining therapies that physicians did not prioritize RT involvement and oftentimes had minimal interaction or collaboration with RTs regarding the withdrawal process once the orders were written. “For the doctors, it’s always been a matter of fact process, it’s an order that they put in.” “Doctors aren’t really physically, or I would even say mentally, involved.” Conversely, one participant discussed the physician’s role as with the family in the decision-making process rather than the act of extubation, which is a role of RT. “The doctors mainly have interaction with the family. They’re the ones helping them get to the decision that they’re making as far as the end-of-life.”
Subtheme 1B: Underappreciating RTs’ Role in Withdrawal of Advanced Life-Sustaining Therapies Process.
Participants also reported low sense of appreciation for the key role RTs play in the withdrawal of advanced life-sustaining therapies process at times. “We are not really involved. We are basically just called in, ‘Hey we’re going to terminally extubate this patient,’ and that is it.” Some were insulted to come into the room only to turn the ventilator off, whereas others were more comfortable with not being intimately involved in the process. “We are always told last minute about what’s going to take place … a lot of times it is just flipping of a button, but it’s a person that’s flipping the button.” “They (physicians) don’t even get your name right.”
Subtheme 1C: Wanting a Voice and Having It Heard.
This subtheme entails both internal and external issues with communication. Internal struggles revealed some participants felt they did not have a right to a voice, whereas others spoke about self-censorship and their own struggle to find their voice in the withdrawal of advanced life-sustaining therapies process and within the health care team. RTs commented, “I know I can’t ask questions, but …” “I’m just an RT… withdrawing care, we really don’t have a say.” Additionally, those who had a voice lacked opportunities to share their thoughts and ideas throughout the withdrawal process. The decision leading up to withdrawal of advanced life-sustaining therapies is one from which RTs often felt disenfranchised.
The desire for quality communication and collaboration with the patient’s RN, physician, and family members prevailed for RTs during the withdrawal of advanced life-sustaining therapies process. RTs reported frequent communication breakdown on several levels. Lack of RT inclusion in family meetings or the decision process to change focus of care to comfort-focused was common “… because I was not in the meeting, I was not in the conference, I was not part of the conversation, I felt like it did not matter what I recommended. It did not matter what I wrote [in the chart].” One RT, however, spoke of a positive experience with a physician who appreciated RT input, “I love it because she’ll come and talk to me or talk to an RT and get our take on what’s going on and just go right to the family.” RNs did not always adequately inform RTs regarding the specific plan and considerations for stopping advanced life support, leading to inadequate preparation time for the process and feelings of being underappreciated. Reliance on RNs to be prepared and coordinate the process was important to RTs to ease stress and share the burden of the emotion-laden charge “… we as RTs can talk to nursing and formulate a plan to how we talk to the family members, what we’re doing to the patient.”
One RT summed up the reason teamwork is vital when caring for a patient receiving comfort care as, “… because it’s not just the patient who is in ‘comfort care,’ it’s the people who have worked with that patient and also the family that need comfort care.”
Theme 2: RTs Need Tools to Provide a Quality Withdrawal of Advanced Life-Sustaining Therapies
An additional global theme from the data was desire of RTs to improve performance of withdrawing advanced life-sustaining therapies for their patients and their families through better communication with colleagues and families and gainful education in different aspects of the dying process.
Subtheme 2A: Education and Clarification of RT Role Expectation.
Most participants spoke about need for formal training and education for the withdrawal of advanced life-sustaining therapies process in both prelicensure education and on-the-job training. They acknowledged, “I realized there’s no guidebook, there’s nothing to tell you how to do this,” and “there should be more training or something.” Many withdrawal processes described were either RTs’ initial experience withdrawing advanced life-sustaining therapies or occurred within the first year of their practice.
Several participants asked for establishing and adhering to a hospital protocol with steps to help support a smooth withdrawal of advanced life-sustaining therapies so that role expectations for RTs, RNs, and physicians during withdrawal of advanced life support would be overt and ideally understood and adhered to by all involved. “But I’d like it if there was something set up where we had defined steps, this is how we compassionately extubate…” One participant’s suggestion for quality withdrawal processes included a pre-withdrawal huddle to review priorities or concerns with individual patients and families, and to discuss expectations, followed by a post-withdrawal discussion regarding what went well and what could be improved.
Subtheme 2B: Tools to Help Communicate/Support/Educate the Family.
Participants described a need to know how to better support families in their suffering and sadness. Some RTs described feeling unsure if they were doing the right thing or if they could have done more to help the patient and family through the dying process. Establishing some basic rapport with the family before withdrawal of advanced life-sustaining therapy helped to provide meaning for RTs. “It seems like it could be better preparation for the family, too, if we were more involved, because we are such a physical part of the EOL process for that family member. Yes, the RN does that, too, but that physical tube, I think, is what they think of, that really is the end.” Several participants underscored their role in helping to support families through the compassionate extubation process. “I’m not in there just to pull the plug. I’m dealing with people as well.” They are often educating the family along with other clinicians and providers. Despite this expectation of education, RTs voiced uncertainty in their ability to answer questions appropriately and being uncomfortable with how to properly respond or support families at times.
Presence of family members during the withdrawal of advanced life-sustaining therapies process may heighten RTs’ stress for different reasons. A crowded room can make navigating medical equipment more difficult. Family rituals described were unnerving to the RT if they were perceived as foreign, obtrusive, or loud. Some were concerned with their own emotional response in front of family and/or found it difficult to bear witness to the sadness and sense of loss in the room.
Theme 3: Emotional Involvement/Exposure
The final global theme focuses on the emotional aspects of withdrawing advanced life-sustaining therapy experience for RTs. Each compassionate extubation experience seemingly disheartened RTs’ connections to patients over time. This protective measure deepened RTs’ perspectives and ignited deeper understanding: RTs play an integral part in promoting patients’ quality of death during withdrawal of life-sustaining therapies. After withdrawal of advanced life-sustaining therapy, a few RTs described a desire to continue to play a role in the process, to support the family in some way despite feeling disconnected from the medical team. Similar to other members of the medical team, RTs become emotionally invested in outcomes of patients and families, and the ability to support families and loved ones (such as offering a place for families to pray at the hospital) was viewed as important and supportive by RTs to allow closure in the relationship. Without the ability to offer support, RTs may experience emotional ambivalence that could lead to stress, decreased job fulfillment, and burnout.
Subtheme 3A: The Weight of the Physical Act of Withdrawing Advanced Life-Sustaining Therapies.
There is a process and an art to performing a quality withdrawal of advanced life-sustaining therapies. In general, the process of withdrawal entails providing oral suctioning of excessive secretions to mitigate sound of fluid in back of throat, removing facial tape holding the endotracheal tube in place, deflating the cuff of the endotracheal tube, pulling the endotracheal tube out of the airway and disposing it in an inconspicuous manner, then cleaning the patient’s face and removing any residual marks from facial tape, while ensuring ventilator-related alarms remain silent. Optimally, there is another person, a nurse, assisting the RT as they perform this process, taking gentle caution as to not set off ventilator-related alarms, although this is not usually the case as the RN is often managing other aspects of the process in the room. With such a visual gesture, the physical act of pulling the endotracheal tube out of a patient’s mouth can hold more weight and finality than halting vasoactive infusions or other medical interventions. “The RNs might give the meds, but it’s such a physical act, physically removing the tube, it’s kind of the last stage. I think our part is pretty stressful at times, for not only the family, but for us too. Trying to make an uncomfortable situation comfortable as it can be.” “They don’t know us, we don’t know them. We have to do the best for this family the best we can.” Sometimes families approached the RT after withdrawal of advanced life-sustaining therapies, offended and upset that the endotracheal tube was removed, as finality of the event took hold, despite this expectation having been discussed, and at other times they were thanked for their role in the process.
Some participants were able to find deeper meaning in the withdrawal process, an understanding that sometimes the care being provided was more akin to elongation of the dying process rather than prolongation of life. Comprehending death as a natural part of life, even though society does not often view it as such, gave strength to RTs. RTs with this lens on the process of withdrawing advanced life-sustaining therapies reported their participation in withdrawal as more of an honor. Being with patients and families during this sacred aspect of the life cycle brought peace to them. “To me it’s almost like a spiritual event; overflowing compassion with the situation. Nothing is rushed; it’s just a quiet evacuation at that point.”
Subtheme 3B: Deep Ties With Certain Patients.
RTs may develop very close relationships with patients. These bonds may be as personal and deep as those between the patient and their RNs or physicians. This is particularly true for patients who experienced protracted disease trajectories, specifically cystic fibrosis. Frequent and prolonged hospitalizations over years can lead to friendships developing and socializing outside of the hospital. “Her kids call me uncle, that’s how much they knew me.” Transitioning goals of care to comfort after years spent fighting the disease was difficult. When standard respiratory therapies were no longer needed, a sense of helplessness occurred for the RT. That adjustment in care provision was traumatic if the RT did not know of other ways to care for the patient.
Subtheme 3C: Ways of Coping With Emotional Toll.
RTs wanted to have a voice and be heard by their non-RT colleagues regarding the emotional toll. There was no process for them to have closure with their part in the withdrawal process. Some described a sense of emotional isolation from non-RT colleagues. “It makes you very sad and really the only ones that can truly understand are your other RTs that you work with.” One RT reported wearing a mask to hide her tears and sadness during the process. Others felt they had developed the ability to compartmentalize their emotions so they could get on with rest of their shift. “… still, respiratory is still just turning that button off and quietly exiting out of the room and with that goes all of the feelings that we have with it.” “I think you have to get to the point where you’re compassionate with people but you have to turn off your emotions pretty quickly after because it’s an ICU environment and you have to move on to your next task.” It seemed to them that only other RT colleagues understood the emotional toll.
Discussion
This study aimed to garner a better understanding of the lived experience of RTs withdrawal of advanced life-sustaining therapies in an adult medical-surgical, non-trauma ICU setting in a single academic tertiary hospital prior to the COVID pandemic. The 3 major themes that emerged from the results of this study: (1) the impact of power relations surrounding the process, (2) needing tools to provide quality withdrawal of advanced life-sustaining therapy, and (3) emotional involvement/exposure confirms and deepens understanding of the lived experience of RTs during withdrawal of advanced life-sustaining therapy.
EOL care is a collaborative effort, and early dialogue will create understanding and consistency across team members, especially if that dialogue includes role definitions.22,23 Communication is paramount for an optimally functioning team, and within that team, each role should be defined.24 Lack of collaboration among professions in ICU settings often leads to poor teamwork and coordination of care, which ultimately hinders the provision of ideal care.25 The Society of Critical Care Medicine’s 2017 Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU underscore the importance of quality communication between clinicians and family to increase family satisfaction and decrease anxiety.26 Efstathiou et al,27 in a 2020 systematic review, acknowledged the importance of, but often lacking, transmission of detailed information between family and care team to better prepare family members for the process of terminal extubation.27
The impact of power relations surrounding the withdrawal of advanced life-sustaining therapy process perfused most of the data. Frackler, Chambers, and Bourobbiere28 state power relations in health care as inequality of power distribution among the interdisciplinary team. Power relations in the hospital setting is not a new concept for RNs, and it occurs on a daily basis across and within professions.28 RTs reported a sense of underappreciation of the dying process and for their role in conducting a quality withdrawal. Some talked about how withdrawal of advanced life-sustaining therapy was considered a task in how they measure the productivity of their day by their RT leadership rather than the emotional event that it is. Participants experienced a sense of being disenfranchised from the process and decisions leading up to the withdrawal process due to lack of communication between RTs and the rest of the health care team, which has also been mentioned in literature with RNs.15 Underappreciated feelings of RTs could also be based on a sense of exclusion given the lack of communication and involvement in the planning process noted by RTs. A need for a collaborative team effort for better planning and timing of withdrawing mechanical ventilation within the overall withdrawal of advanced life support was reported. Communication and teamwork are essential skills for RTs,29 but the findings reveal this is an area where RTs may need to advocate on their own behalf for increased involvement in decisions related to plan of care. RTs questioned if they even had a right to have a voice. Internal hesitation or self-censoring by RTs was reported. As previously mentioned, this lends itself to the struggle with power and the idea that RTs do not hold a position on the palliative care team and, on some level, are uncertain whether they deserve to. RTs who did feel empowered enough to ask questions did not feel heard in planning withdrawal of advanced life support. Feelings of disenfranchisement were evidenced by RTs as they verbalized immense gratitude for this dialogue opportunity. Findings from this study illustrate the impact of power relations enveloping withdrawal of advanced life-sustaining therapies for RTs.
In reviewing literature on the protocols, procedures, and discussions about EOL care in the ICU, the role of the RT is rarely mentioned and then only as one of the team members. In 2014, the Canadian government sponsored a systematic review with guidelines of care for EOL planning. This analysis included over 5,300 studies, reviews, and randomized controlled trials, yet RTs were not mentioned as being members of the care team for EOL care or discussions.30 In the United States, the Campbell systematic review of 2007, along with a worldwide survey in 2014 by Paruk, described clinician duties without mention of the RT role in particular2,11,12 and does not mention RTs, specifically, as participants in a survey of 32 countries to form a consensus on EOL principles. In fact, in the popular RT instructional textbook Pilbeam’s Mechanical Ventilation: Physiological and Clinical Applications, 7th edition, there is little mention of terminal weaning nor withdrawal of advanced life-sustaining therapies when managing an EOL intubated patient.31 Guidelines published through the work of an interdisciplinary Canadian team, including RTs, recommended RTs be included in the plan of care and be educated on the grieving process.32 A document developed by the Center to Advance Palliative Care calls for exceptional communication among all clinical staff along with awareness that a team approach is required for optimal EOL care.33 It also calls for “adequate training and clinical support to assure that professional staff are confident in their ability to provide palliative care for patients”33 and that the plan of care should be “broadly disseminated to all professionals involved in the patient’s care.” 33 Efstathiou et al concluded that experiences and practices vary in different parts of the world and, overall, contain much ambiguity.27
Thus, qualitative findings of RTs interviewed for this study are consistent with what is missing in the literature in terms of their contribution and recognition for EOL conversations and procedural planning. With a better understanding of their lived experience of withdrawal of advanced life-sustaining therapies, appropriate steps can be taken to safeguard RTs from distress or burnout and improve collaboration among health care providers at EOL, which could potentially improve the withdrawal process for patients, families, and clinicians.
Limitations of this study were that participants came from one tertiary-care center and worked in an adult ICU setting. Although, data saturation was reached at this center, the sample size of 8 was small, which could represent sample bias. For these reasons, the study may not be transferable, particularly to those RTs working in a pediatric or neonatal ICU. The study was strictly phenomenological, exploring perspectives of RTs during withdrawal of advanced life-sustaining therapy, and specific details surrounding education received were not collected. It is worth mentioning, again, that these findings were pre-pandemic. The pandemic exacerbated the number of withdrawals of advanced life-sustaining therapy at a rapid pace and in a short amount of time. Team communication was challenged, and withdrawals, oftentimes, occurred under distressful circumstances without family members present. The full impact to RT emotional stress and burnout is yet to be seen. A repeat study today may uncover different findings.
Implications for Practice
RTs wanted to have a voice and be heard by family members and other health care providers. Improved collaboration and a sense of empowerment for RTs could be achieved through improved EOL education in RT prelicensure school, multidisciplinary education in the workplace, participation in ethics committee decision-making, and involvement in the development of policy and procedure both at the hospital and professional organization levels. Education about grief, spirituality, and cultural considerations surrounding the dying process may be helpful for RTs to put their experiences into context and understand their role during EOL. With EOL education, RTs may be empowered to support families through education about expected signs and symptoms of the active dying process. It could also help them accept the myriad customs people use to respond to loss and sadness, thus helping to combat feelings of discomfort experienced and sometimes reported. Furthermore, policy and procedure development will assist with role development of the RT during planning, actual process, and through debriefing. The need for improved mentoring of novice RTs, by an experienced RT, through at least their first one or 2 withdrawal experiences will help ensure they learn the basics of quality withdrawal for their future practice.
The act of withdrawing advanced life-sustaining therapy did not come without emotional burden for many RTs. Providing a post huddle or debrief session, as suggested by several RTs, could alleviate that toll, provide an outlet for shared coping between interdisciplinary team members, and establish their significance within the health care team. This need is heightened with those patients with deep ties. An education with a holistic perspective may enable RTs to fully understand how to care for patients in the presence of medical futility and decrease the risk of sense of failure and ineffective coping, which may lead to behaviors that are contrary to caring, and burnout.
The aforementioned discussion of this study coincides with previous survey findings stating RTs want to be more involved in family meetings and the decision-making process leading up to withdrawal of advanced life support for their patients, more education and training about the active dying process, and for more explicit protocols to be used more often.10,15,16 Involvement in interdisciplinary rounds should not be excluded as well as review of staffing models to permit time for involvement. Table 2 summarizes themes with suggestions for changes or interventions that may be incorporated into practice settings. Items in the table are derived from guidelines,26,32 literature,29 findings from the study, and analysis of findings from the interdisciplinary research team comprised of an RT and nurses with combined experience over 30 years in the critical care setting.
Conclusions
This phenomenological approach has added to the current knowledge a deeper understanding and appreciation for RTs’ lived experience of withdrawal of advanced life-sustaining therapy. Identifying the 3 major themes of experiences of RTs who must complete withdrawal of advanced life-sustaining therapy provides a better understanding of RTs’ role in the process. Best practices for care, needed and desired by RTs in this study, include preparation, education, and involvement of the entire team in the withdrawal process. EOL care should be considered an essential competency for longevity and emotional health of the RT workforce and may, partly, be accomplished through education with respiratory care organizations at the national level. After data collection, the nurse-led palliative care committee actively invited RTs to attend a series of palliative care educational classes originally aimed at nurses. The educators adapted the class to be more inclusive of RTs’ priorities. They also provided opportunities for discussion and debriefing of previous traumatic experiences surrounding withdrawal of advanced life-sustaining therapies and EOL care between nurses and RTs. About 10 RTs attended the series of classes and expressed positive feedback in their class evaluations. Ongoing improvements in team dynamics and workforce issues may lead to better incorporation of RTs in discussions surrounding withdrawal of advanced life-sustaining therapies.
Understanding withdrawal of advanced life-sustaining therapies as a sacred process and place can help deepen the meaning of the event for all clinicians involved. The statements offered by RTs in this study clearly indicate that they may not be as involved with withdrawal of advanced life-sustaining therapies as they might like to be or that they feel their role has been overlooked. There can be negative consequences for patients and clinicians when there is a feeling of disempowerment in the clinical setting. With a better understanding of the impact of power relations in the lived experience of RTs during withdrawal of advanced life-sustaining therapies, nursing and other health professionals can move toward mitigating the negative impact on their practice together.
Acknowledgments
The authors recognize Beth Neely for her assistance with manuscript formatting and preparation.
Footnotes
- Correspondence: Kristiana GH Cullum PhD, San Diego State University, School of Nursing, 5500 Campanile Drive, San Diego, CA 92182–4158. E-mail: kcullum{at}sdsu.edu
The authors have disclosed no conflicts of interest.
- Copyright © 2022 by Daedalus Enterprises
