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VOLUME 28 , ISSUE 5 ( May, 2024 ) > List of Articles

Original Article

Semiotics of ICU Physicians’ Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study

Shivakumar Iyer, Rutula N Sonawane, Jignesh Shah, Naveen Salins

Keywords : End-of-life care, Good death, Intensive care unit, Physician, Quality of dying, Views

Citation Information : Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians’ Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024; 28 (5):424-435.

DOI: 10.5005/jp-journals-10071-24696

License: CC BY-NC 4.0

Published Online: 30-04-2024

Copyright Statement:  Copyright © 2024; The Author(s).


Abstract

Background and aim: While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored. Methods: There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes. Results: About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients’ and families’ choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC. Conclusion: Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians.


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  1. Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet 2010;376(9749):1339–1346. DOI: 10.1016/s0140-6736(10)60446-1.
  2. Murthy S, Leligdowicz A, Adhikari NK. Intensive care unit capacity in low-income countries: A systematic review. PLoS One 2015;10(1):e0116949. DOI: 10.1371/journal.pone.0116949.
  3. Engdahl Mtango S, Lugazia ER, Baker U, Johansson YA, Baker T. Referral and admission to intensive care: A qualitative study of doctors’ practices in a Tanzanian university hospital. PLoS ONE 2019;14(10):e0224355. DOI: 10.1371/journal.pone.0224355.
  4. Braganza MA, Glossop AJ, Vora V. Treatment withdrawal and end-of-life care in the intensive care unit. BJA Education 2017;17(12):396–400. DOI: 10.1093/bjaed/mkx031.
  5. Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, et al. End-of-life practices in European intensive care units: The Ethicus Study. JAMA 2003;290(6):790–797. DOI: 10.1001/jama.290.6.790.
  6. Kapadia F, Singh M, Divatia J, Vaidyanathan P, Udwadia FE, Raisinghaney SJ, et al. Limitation and withdrawal of intensive therapy at the end of life: Practices in intensive care units in Mumbai, India. Crit Care Med 2005;33(6):1272–1275. DOI: 10.1097/01.ccm.0000165557. 02879.29.
  7. Mani RK. Limitation of life support in the ICU: Ethical issues relating to end of life care. Indian Journal of Critical Care Medicine 2003;7(2):112.
  8. Phua J, Joynt GM, Nishimura M, Deng Y, Myatra SN, Chan YH, et al. Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions. Intensive Care Med 2016;42(7):1118–1127. DOI: 10.1007/s00134-016-4347-y.
  9. Divatia JV, Mehta Y, Govil D, Zirpe K, Amin PR, Ramakrishnan N, et al. Intensive Care in India in 2018–2019: The second Indian intensive care case mix and practice patterns study. Indian J Crit Care Med 2021;25(10):1093–1107. DOI: 10.5005/jp-journals-10071-23965.
  10. Barnett VT, Aurora VK. Physician beliefs and practice regarding end-of-life care in India. Indian J Crit Care Med 2008;12(3):109–115. DOI: 10.4103/0972-5229.43679.
  11. Myatra SN, Salins N, Iyer S, Macaden SC, Divatia JV, Muckaden M, et al. End-of-life care policy: An integrated care plan for the dying: A joint position statement of the Indian Society of critical care medicine (ISCCM) and the Indian Association of Palliative Care (IAPC). Indian J Crit Care Med 2014;18(9):615–635. DOI: 10.4103/0972-5229.140155.
  12. Iyer S. Challenges in the implementation of “end-of-life care” guidelines in India: How to open the “Gordian Knot”? Indian J Crit Care Med 2014;18(9):563–564. DOI: 10.4103/0972-5229.140140.
  13. Chacko R, Anand JR, Rajan A, John S, Jeyaseelan V. End-of-life care perspectives of patients and health professionals in an Indian health-care setting. Int J Palliat Nurs 2014;20(11):557–564. DOI: 10.12968/ijpn.2014.20.11.557.
  14. Rao SR, Rao KS, Singhai P, Gupta M, Rao S, Shanbhag V, et al. COVID-19 Palliative and end-of-life care plan: Development and audit of outcomes. Indian J Palliat Care 2022;28(3):272–279. DOI: 10.25259/ijpc_59_2021.
  15. Rao SR, Salins N, Joshi U, Patel J, Remawi BN, Simha S, et al. Palliative and end-of-life care in intensive care units in low- and middle-income countries: A systematically constructed scoping review. J Crit Care 2022;71:154115. DOI: 10.1016/j.jcrc.2022.154115.
  16. Patton MQ. Sampling, qualitative (purposive). The Blackwell encyclopedia of sociology. 2007. DOI: https://doi.org/10.1002/9781405165518.wbeoss012.
  17. Braun V, Clarke V, Hayfield N, Terry G. Thematic analysis. In: Liamputtong P (Eds). Handbook of research methods in health social sciences. Singapore: Springer; 2019. pp. 843–860. DOI: https://doi.org/10.1007/978-981-10-5251-4_103.
  18. Braun V, Clarke V. To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qualitative Research in Sport, Exercise and Health 2021;13(2):201–216. DOI: 10.1080/2159676X.2019.1704846.
  19. Pawson R. Theorizing the interview. Br J Sociol 1996;47(2):295–314. DOI: https://doi.org/10.2307/591728.
  20. Danermark B, Ekström M, Karlsson JC. Explaining society: Critical realism in the social sciences (2nd ed.). Routledge; 2019. DOI: https://doi.org/10.4324/9781351017831.
  21. Dodgson JE. Reflexivity in qualitative research. J Hum Lact 2019;35(2):220–222. DOI: 10.1177/0890334419830990.
  22. Matus P. Discursive representation: Semiotics, theory, and method. Semiotica 2018;225:103–127. DOI: 10.1515/sem-2017-0019.
  23. Chandler D. Semiotics For Beginners. 2011. Available from: https://www.semanticscholar.org/paper/Semiotics-For-Beginners-Chandler/d540341246102f1d7f82dcdb62f338548a3ea8b0.
  24. Riera JJ. Semiotic theory. Theoretical Models for Teaching and Research. 2022. Available from: https://opentext wsu edu/theoreticalmodelsfor teachingandresearch/chapter/semiotic-theory.
  25. Johnstone R, Fowell AJ. Quality end of life care. BMJ Supportive & Palliative Care 2012;2:A54–A54.
  26. Andrew EVW, Cohen J, Evans NC, Meñaca A, Harding R, Higginson I, et al. Social-cultural factors in end-of-life care in Belgium: A scoping of the research literature. Palliat Med 2013;27(2):131–143. DOI: 10.1177/0269216311429619.
  27. Boissier F, Seegers V, Séguin A, Legriel S, Cariou A, Jaber S, et al. Assessing physicians’ and nurses’ experience of dying and death in the ICU: Development of the CAESAR-P and the CAESAR-N instruments. Crit Care 2020;24(1):521. DOI: 10.1186/s13054-020-03191-z.
  28. Krikorian A, Maldonado C, Pastrana T. Patient's perspectives on the notion of a good death: A systematic review of the literature. J Pain Symptom Manage 2020;59(1):152–164. DOI: https://doi.org/10.1016/j.jpainsymman.2019.07.033.
  29. Meier EA, Gallegos JV, Thomas LP, Depp CA, Irwin SA, Jeste DV. Defining a good death (Successful Dying): Literature review and a call for research and public dialogue. Am J Geriatr Psychiatry 2016;24(4):261–271. DOI: 10.1016/j.jagp.2016.01.135.
  30. Zaman M, Espinal-Arango S, Mohapatra A, Jadad AR. What would it take to die well? A systematic review of systematic reviews on the conditions for a good death. Lancet Healthy Longev 2021;2(9): e593–e600. DOI: 10.1016/s2666-7568(21)00097-0.
  31. Trankle SA. Is a good death possible in Australian critical and acute settings?: Physician experiences with end-of-life care. BMC Palliat Care 2014;13:41. DOI: 10.1186/1472-684x-13-41.
  32. Downey L, Curtis JR, Lafferty WE, Herting JR, Engelberg RA. The quality of dying and death questionnaire (QODD): Empirical domains and theoretical perspectives. J Pain Symptom Manage 2010;39(1): 9–22. DOI: 10.1016/j.jpainsymman.2009.05.012.
  33. Balakrishna K, Ramasamy T, Venketeswaran MV. Initiation of palliative care referral from the intensive care unit for advanced stage metastatic cancer patients: A quality improvement process from a tertiary referral cancer institute from South India. Indian J Palliat Care 2023;29(4):412–417. DOI: 10.25259/IJPC_267_2022.
  34. Lebaron V, Beck SL, Maurer M, Black F, Palat G. An ethnographic study of barriers to cancer pain management and opioid availability in India. Oncologist 2014;19(5):515–522. DOI: 10.1634/theoncologist.2013-0435.
  35. Luckett A. End-of-life care guidelines and care plans in the intensive care unit. Br J Nurs 2017;26(5):287–293. DOI: 10.12968/bjon.2017.26.5.287.
  36. Vink EE, Azoulay É, Caplan AL, Kompanje EJO, Bakker J. Time-limited trial of intensive care treatment: An overview of current literature. Intensive Care Med 2018;44(9):1369–1377. DOI: 10.1007/s00134-018-5339-x.
  37. Sprung CL, Joynt GM, Christian MD, Truog RD, Rello J, Nates JL. Adult ICU triage during the coronavirus disease 2019 pandemic: Who will live and who will die? Recommendations to improve survival. Crit Care Med 2020;48(8):1196–1202. DOI: 10.1097/ccm.0000000000004410.
  38. Krishna LKR, Neo HY, Chia EWY, Tay KT, Chan N, Neo PSH, et al. The role of palliative medicine in ICU bed allocation in COVID-19: A joint position statement of the Singapore Hospice Council and the chapter of palliative medicine physicians. Asian Bioeth Rev 2020;12(2):205–211. DOI: 10.1007/s41649-020-00128-0.
  39. Kynoch K, Chang A, Coyer F, McArdle A. Developing a model of factors that influence meeting the needs of family with a relative in ICU. Int J Nurs Pract 2019;25(1):e12693. DOI: 10.1111/ijn.12693.
  40. Azoulay E, Pochard F, Chevret S, Lemaire F, Mokhtari M, Le Gall JR, et al. Meeting the needs of intensive care unit patient families: A multicenter study. Am J Respir Crit Care Med 2001;163(1):135–139. DOI: 10.1164/ajrccm.163.1.2005117.
  41. Salins N, Deodhar J, Muckaden MA. Intensive care unit death and factors influencing family satisfaction of Intensive Care Unit care. Indian J Crit Care Med 2016;20(2):97–103. DOI: 10.4103/0972-5229.175942.
  42. Ferrante LE. Prognostication during critical illness: Moving the field forward. Ann Am Thorac Soc 2017;14(10):1510–1511. DOI: 10.1513/AnnalsATS.201706-496ED.
  43. Tros W, van der Steen JT, Liefers J, Akkermans R, Schers H, Numans ME, et al. General practitioners’ evaluations of optimal timing to initiate advance care planning for patients with cancer, organ failure, or multimorbidity: A health records survey study. Palliat Med 2021;36(3):510–518. DOI: 10.1177/02692163211068692.
  44. Harden KL, Price DM, Bigelow AD, Mason H. Phases and transitions of serious illness: A structure for teaching palliative care. J Nurs Educ 2023;62(5):279–284. DOI: 10.3928/01484834-240230306-05.
  45. Sallnow L, Smith R, Ahmedzai SH, Bhadelia A, Chamberlain C, Cong Y, et al. Report of the lancet commission on the value of death: Bringing death back into life. Lancet 2022;399(10327):837–884. DOI: 10.1016/s0140-6736(21)02314-x.
  46. Jenkins AC. Empathy affects tradeoffs between life's quality and duration. PLoS One 2019;14(10):e0221652. DOI: 10.1371/journal.pone.0221652.
  47. Kapo JM, Siegel MD. Penguins and palliative care: Facilitating cultural change in the ICU. Crit Care Med 2013;41(10):2443–2444. DOI: 10.1097/CCM.0b013e31829136f3.
  48. Peter JV, Thomas K, Jeyaseelan L, Yadav B, Sudarsan TI, Christina J, et al. Cost of intensive care in India. Int J Technol Assess Health Care 2016;32(4):241–245. DOI: 10.1017/S0266462316000398.
  49. Dasgupta S, Chandra A. Rational quality and cost of critical care systems are more important than individual considerations: A view from India. Postgrad Med J 2023;99(1177):1207–1209. DOI: 10.1093/postmj/qgad068.
  50. Leng A, Jing J, Nicholas S, Wang J. Catastrophic health expenditure of cancer patients at the end-of-life: A retrospective observational study in China. BMC Palliat Care 2019;18(1):43. DOI: 10.1186/s12904-019-0426-5.
  51. Reddy KN, Shah J, Iyer S, Chowdhury M, Yerrapalem N, Pasalkar N, et al. Direct medical cost analysis of Indian COVID-19 patients requiring critical care admission. Indian J Crit Care Med 2021;25(10):1120–1125. DOI: 10.5005/jp-journals-10071-23991.
  52. Townsend SC, Hardy JR. End-of-life decision-making in intensive care: The case for an international standard or a standard of care? Intern Med J 2008;38(5):303–304. DOI: 10.1111/j.1445-5994.2008.01654.x.
  53. Forman EN, Ladd RE. Why not a slow code? Virtual Mentor 2012;14(10):759–762. DOI: 10.1001/virtualmentor.2012.14.10.ecas1-1210.
  54. Kon AA. Informed non-dissent: A better option than slow codes when families cannot bear to say “Let Her Die”. Am J Bioeth 2011;11(11): 22–23. DOI: 10.1080/15265161.2011.603796.
  55. Bosslet GT, Pope TM, Rubenfeld GD, Lo B, Truog RD, Rushton CH, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med 2015;191(11):1318–1330. DOI: 10.1164/rccm.201505-0924ST.
  56. Kayser JB, Kaplan LJ. Conflict management in the ICU. Crit Care Med 2020;48(9):1349–1357. DOI: 10.1097/ccm.0000000000004440.
  57. Barrett H, Bion J. Cobatrice core competencies and syllabus development: 54. Critical Care Medicine 2005;33(12):A14.
  58. Schwarzkopf D, Rüddel H, Thomas-Rüddel DO, Felfe J, Poidinger B, Matthäus-Krämer CT, et al. Perceived nonbeneficial treatment of patients, burnout, and intention to leave the job among ICU nurses and junior and senior physicians. Crit Care Med 2017;45(3):e265–e273. DOI: 10.1097/ccm.0000000000002081.
  59. Livne R. Toward a sociology of finitude: Life, death, and the question of limits. Theory Soc 2021;50(6):891–934. DOI: 10.1007/s11186-021-09448-y.
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