Integrity at end of life in the intensive care unit: a qualitative study of nurses' views

Background Integrity is a core value for delivering ethical health care. However, there is a lack of precision in defining what integrity is and how nurses understand it. In the setting of nurses caring for critically ill and dying patients in intensive care units (ICUs), integrity has not received much attention. Therefore, the aim of this study was to explore how nurses perceive and maintain the integrity of patients during end-of-life care in the ICU setting. Methods This study had a qualitative descriptive design. Data were collected using individual semi-structured interviews with 16 intensive care nurses working at ICUs in four Swedish hospitals. The data were analysed by applying qualitative content analysis. Results Five overall categories were explored: seeing the unique individual; sensitive to patient vulnerability; observant of patients' physical and mental sphere; perceptive of patients' religion and culture; and being respectful during patient encounters. Many nurses found it difficult to define integrity and to explain what respecting integrity entails in the daily care of dying patients. They often used notions associated with respect and patient-centred attitudes, such as listening and being sensitive or by trying to describe good care. Integrity was nonetheless seen as a central value for their clinical work and a precondition for ethical nursing practice. Some nurses were concerned about patient integrity, which is at risk of being wiped out due to the patient's illness/injury, unfamiliarity with the ICU environment and utter dependence on others for care. Protecting patients from harm and reducing patient vulnerability were also seen as important and a way to maintain the integrity of patients. Conclusions The study results show that even though integrity is a fundamental ethical concept and a core value in nursing, ethical codes and guidelines are not always helpful in clinical situations in the end-of-life care of ICU patients. Hence, opportunities must regularly be made available for ICU nurses to reflect on and discuss ethical issues in terms of their decision-making and behaviour.

Automated summary

Integrity is seen as a fundamental ethical concept and a core value in nursing, but nurses often struggle to define and explain it in the context of daily care for dying patients in the ICU. Protecting patients from harm and reducing patient vulnerability are important ways to maintain patient integrity in the ICU setting. The study highlights the importance of providing opportunities for ICU nurses to reflect on and discuss ethical issues in decision-making and behavior.