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Witness
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Inferences
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| “I’ve worked in other ICUs and there is a comparison of end-of-life expectancy in each one. In oncology, it is clear because the patient is admitted and palliative care starts immediately” (Nursing P24). “This is not an ICU whose mortality rate is due to inadequate care, but because patients arrive here already in a critical state, making us an ICU that provides end-of-life care [...]” (Physiotherapy P6). |
High complexity of the profile of patients, related to rapid evolution of the disease, aggressive treatment and high mortality. |
| “It is difficult to define patients where there is no hope of recovery. I imagine due to lack of knowledge and difficulty in assuming risk [...]” (Physiotherapy P12). |
Lack of knowledge on the subject. Delay in establishing the prognosis. Concerns about ethical and legal repercussions. |
| “I think we have more end-of-life than intensive care patients in our sector, two for every one, so either we need to rethink which patients come here or receive more information about palliative care” (Nursing P25). |
Predominance of patients receiving end-of-life in the oncology ICU. Need to screen each case to facilitate appropriate indication of critical care, as well as for ongoing education. |
| “We are highly limited to few types of care; the truth is we do the basics, which is to alleviate pain. We could provide more comprehensive support or perhaps offer palliative care much earlier. After the person is intubated, then sedated, I think morphine and palliative care could be started [...]” (Medicine P18). |
Medication as the main approach for relieving symptoms. Insistence on therapeutic intervention and undermining the patient’s autonomy. Need for early integration of critical and palliative care. |
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Category 2. Promoting the patient’s comfort in end-of-life care in the oncology ICU
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Witness
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Inferences
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| “The dedication of professionals must remain the same; what changes is the care focus, which shifts more to treating symptoms [...]” (Medicine P8). |
Promotion of comfort as a care planning goal. Focus on physical symptoms. |
| “[...] maintain physical integrity, respect for the body, for the life therein, for the family coming to see the patient, who wants, as much as possible, to see the patient, as being presentable and looking cared for [...]” (Nursing P10). |
Respect for the body. Sensitivity in caring for the family’s needs, ensuring the person’s dignity, seeking to provide care based on a clean and comfortable appearance. |
| “Do not perform any procedure, any invasive testing, nothing that requires transportation, nor create any type of discomfort such as glycemic monitoring or finger insertion, try to leave the patient properly hooked up, which is what you have here, mechanical ventilation, do not treat hypotension, let things flow according to the natural course of the disease” (Medicine P22). |
Minimize futile therapy to promote comfort, while at the same time employing technological resources to prolong life, which is contradictory. |
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Category 3. Limits and challenges in planning end-of-life care for patients in the oncology ICU
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Witness
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Inferences
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| “Palliative care does not go with intensive care. Patients are cared for because they occupy a bed, but there is no direct relationship with the activities of this unit [...]” (Medicine P20). “[...] A patient with no hope of recovery occupies a place that could be for a patient that has possibilities. I think that such palliative care patients could have better quality of life staying with their family rather than coming to the ICU, being subjected to invasive and unnecessary procedures [...]” (Nursing P1). |
Incompatibility between critical and palliative care. Inappropriate indication of intensive care. Patients with no reasonable expectation of recovery should not be admitted to the ICU, since they will not benefit from it. |
| “The objective is usually determined by the person who will provide the treatment, i.e., the physician. So, if the situation is defined by the physician as without hope, or if he or she is unable to establish this... we get mixed up in our objectives as well [...]” (Physiotherapy P12). |
Decision-making limited to the physician. Difficulty working as a team and communicating. |
| “It’s tiring to look after a patient where nothing has been established, since one day you have to do everything and then the next day you undo it all. This is not good from a technical perspective and even worse emotionally [...]” (Nursing P25). |
Professionals are not prepared to deal with patients in the process of dying or with death. Shortcomings in professional training. Indicates the needs for emotional support. |
| “If a critical patient is always ill in the ICU, regardless of what led to the deterioration, it represents an undue occupation of beds. We act according to the need; this results in pressure, even if disguised; there is no specific place for patients without hope of recovery [...]” (Medicine P20). |
Need to establish palliative care nursing. Complex ethical questions that may involve legal decisions and institutional policy. |
