Professional Documents
Culture Documents
Published by:
http://www.sagepublications.com
Additional services and information for Nursing Ethics can be found at: Email Alerts: http://nej.sagepub.com/cgi/alerts Subscriptions: http://nej.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations (this article cites 23 articles hosted on the SAGE Journals Online and HighWire Press platforms): http://nej.sagepub.com/cgi/content/refs/14/5/651
Downloaded from http://nej.sagepub.com by RAVI BABU BUNGA on November 8, 2007 2007 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
Introduction
In any medical setting, the most important factors that must be considered in determining a treatment plan are the wishes and autonomy of the patient. However, many patients who require intensive treatment have diminished consciousness as a result of their illness, sedation or analgesia. A treatment plan must therefore often be determined without being able to ascertain these patients wishes. This raises ethical problems when deciding whether to withdraw or withhold intensive treatment for patients with poor prognoses.1 In Japan, the social practice of preparing a living will while still healthy is not well established. Even in cases where a physician has continued with life-prolonging treatment despite the patients rejection of such treatment in a living will, ignoring such advance directives has not been challenged as illegal. A living will has no legal
Address for correspondence: Satomi Kinoshita, Kanagawa University of Human Services, Faculty of Health & Social Work, School of Nursing, 1-10-1 Heiseicho, Yokosuka Kanagawa, Japan 238-8522. Tel: /81 46 828 2534; Fax: /81 46 828 2635; E-mail: kinoshita-s@kuhs.ac.jp
10.1177/0969733007075890
Downloaded from http://nej.sagepub.com by RAVI BABU BUNGA on November 8, 2007 2007 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
652
S Kinoshita
standing in Japan, and the concept has not been generally accepted in Japanese society.2 These circumstances mean that nurses working in an intensive care unit (ICU) have to confront ethical problems related to end-of-life decision making. Several reports from other countries have indicated that deaths in ICUs contribute to high stress levels being experienced by nurses3 7 and have described the conflicts that they face regarding life-prolonging treatment and patients rights to self-determination.8 10 However, few studies on ICU deaths and end-of-life care in Japan have been conducted, and cultural differences appear to prevent findings in other countries from being applied directly to Japan. In an overview of studies examining nurses perceptions regarding the wishes of endstage patients in general, Sendai and Tanka11 reported that nurses accept do-notresuscitate (DNR) orders and expressed the opinion that, despite their opposition to this approach, patients wishes should be respected. This view was not expressed by physicians and the general public, only by nurses. Sugawara12 examined the ethical dilemmas perceived by clinical nurses involved in end-of-life care and found that these included conflict between patients wishes (principle of autonomy) and physicians principle of benevolence, as well as the perceived inadequacy of information provided by physicians to patients or their families when informed consent is obtained. In an investigation of end-of-life care in the ICU, Yoko13 examined neonatal ICU nurses perceptions concerning treatment decisions in various situations and found that they considered futile prolongation of life to be a form of unethical treatment. Takano14 reported that many ICU nurses regard end-of-life care as difficult because they believe it is important to provide treatment and approaches to dying patients that comply with their wishes, but they are unable to do so. More ICU nurses than general nurses believed that patients wishes are not respected during the process of dying. These investigations have shown that, in an ICU setting where patients are dying, nurses feel they are caught in ethical dilemmas that complicate end-of-life care. However, no published research has investigated the causes of these perceptions or examined them in detail. Although the literature contains several reports of assistance in end-of-life decision making, most of these patients had chronic, end-stage disease and were receiving care in a general ward or at home.15,16 Relatives make end-of-life decisions for ICU patients who cannot make them for themselves, thus many studies have examined decision making by family members. Tateishi et al.17 examined the attitudes of physicians and relatives in the absence of patient autonomy during end-of-life care in the ICU, including when the expression of patients wishes was difficult due to sedative use or decreased cognitive function. They found that, even if the patient had previously instructed that life-prolonging treatment should be halted in circumstances where treatment was difficult, many physicians would give priority to the question of whether the family had accepted those instructions, rather than following them without consideration of family members attitude. However, there are no assurances that relatives will necessarily infer accurately patients intentions and carry them out on their behalf.18 Previous studies13,14 have shown that nurses providing end-of-life care in an ICU are distressed by the difficulties encountered in supporting patients own desired approach to dying. This appears to be not merely a problem of communication with patients but rather a manifestation of the various ethical problems entailed in such care. The purpose of this study was to clarify why Japanese ICU nurses perceive
653
difficulties in respecting the wishes of patients with end-stage disease and, based on these results, to identify the problems involved in end-of-life decision making.
Method
Study design
The reasons why the Japanese ICU nurses thought it was difficult to respect the wishes of patients were analyzed using content analysis.
Analysis
A coding schema was created for content analysis.19 This was developed after the free narrative responses of the present study were read once and using the results of a previous interview survey of 18 ICU nurses,14 with whom interviews were conducted to ascertain their actions, experiences and feelings relating to death and end-of-life care in the ICU and their thoughts on patients with a terminal illness and their families. The mean duration of these interviews was 50 minutes (range 30 /90) and the contents were grouped as follows: Thoughts about patients; Thoughts about family members; Thoughts about physicians; Thoughts about therapy; Thoughts about end-of-life
654
S Kinoshita
care in ICUs; Thoughts about the self; Thoughts about coworkers; and Thoughts about deaths in the ICU. When creating the coding schema in the present study, the reasons why nurses believed that patients wishes were not being respected were extracted from the interview transcripts and categorized. Next, to confirm whether the coding schema could be used for classification in the present study, the written free narratives obtained from the questionnaires were read again and about 100 answers were classified on a trial basis. This process of classification was used to confirm the appropriateness of the coding schema by renaming, adding and combining categories, eventually identifying 12 categories. These 12 categories were grouped into four themes: Patients wishes unknown; Decisions made by others; ICU functioning unsuitable for end-of-life care; and Characteristics of ICU end-of-life care. To determine whether these themes were applicable to the specific responses they were then cross-checked with statements made during interviews. The 12 categories and their meanings are indicated below according to the themes to which they apply. Patients wishes unknown . Circumstances prevent patients wishes from being determined: The patients wishes cannot be ascertained because of diminished consciousness, and the question of whether the patients wishes are finally complied with could not be answered. Patients admitted as a result of accidents are sometimes unconscious, and their wishes are not reflected; Many patients in the ICU are sedated and their voice cannot be heard. Its sad to see a patient admitted to the ICU while unconscious and die in that state. . Lack of information about patients wishes: There is no-one present who knows the patients wishes and no pertinent information is available: (I think) a person should leave some indication of their wishes. Decisions made by others . Decision-making priority given to the family: Treatment is chosen according to the wishes of the family, regardless of whether the patients wishes are known. Even if I think that it would probably be better to stop a life-prolonging treatment, if the family has not accepted the patients death (regardless of the patients wishes), I have no choice but to continue treatment. . Decision made primarily by a physician: Treatment is determined by the physician regardless of the patients wishes. I have doubts about leaving the treatment decision entirely to the physician. . Experience of settings in which patients wishes were not accepted: The nurses encountered settings in which treatment was continued even though patients had left an indication of their wishes; those wishes were not accepted. Even though patient B had said he did not wish to undergo surgery, the patients family was persuaded by the physician to permit it . . . the patient eventually died after surgery. . Insufficient information provided to patients or families about the possibility of dying: The patient was not informed, and no information about the possibility of
655
dying was provided. Even though an operation has risks, the physicians do not ask the patients about their wishes. Although life-prolonging treatment is futile, the physicians tell the family that there is hope. ICU functioning unsuitable for end-of-life care . The role of the ICU is to save life: The ICU gives priority to lifesaving and cannot grant a patients wish not to undergo treatment. Theres a sense of duty that, because patients are on the ICU, they must be treated. . Treatment is so excessive that patients would probably not want it to be performed: The nurses believe that excessive treatment is provided even in situations where a patients life cannot be saved and that the patient would probably not wish to be treated under these circumstances. Vasopressors are used in large quantities . . . seeing a patient being treated only with drugs has made me wonder whether treating them to keep them alive is really the right thing to do for that person. . The ICU environment is inappropriate for dying: The patients are surrounded by machines, and theres no feeling of freedom. I dont think the patient can feel at peace. Its not a place where I would want to die. Characteristics of ICU end-of-life care . Patients have strong expectations of recovery and are not mentally prepared to die: Patients were admitted to the ICU expecting to recover, not to die. The patients had been awaiting surgery for myocardial infarction and said they wanted to undergo surgery quickly and that surgery would save them. But they died before surgery. . The patients undergo such a change in appearance that they probably would not wish to be treated: At the end of treatment patients appearance changes, and the respondents thought it unlikely that they would wish to have reached that condition. The treatment is prolonged, and the patients appearance changes rapidly due to edema and skin damage . . . it would be better to be able to die while retaining a normal appearance. . Sudden death and time constraints: Time constraints imposed by factors such as rapid deterioration, as in the case of unexpected death and the resulting inability to provide adequate care. With patients for whom bleeding does not stop after surgery and who are in a condition that makes lifesaving difficult, I follow the treatment but I dont know what to do . . . I feel there is nothing I can do as a nurse. Analysis of the free narratives Next, information from the free narratives was classified according to the four themes and 12 categories described above. If one individual provided two or more descriptions, each was coded separately. However, if a participant had multiple descriptions in the same category, only one description was coded for that category. Classification was performed twice by the author, who also sought opinions from a nurse with experience in nursing research who had worked in an ICU for five years. In cases of disagreement, the response was classified after a re-examination.
656
S Kinoshita
Results
Valid responses to the question, Do you feel that patients wishes are respected during the process of dying? were obtained from 1158 of the 1210 respondents. Fifteen participants (1.3%) responded that they thought patients wishes were well respected, 246 (21.2%) that patients wishes were adequately respected, 623 (53.8%) that patients wishes were not adequately respected, and 274 (23.7%) that patients wishes received little respect. Hence, 897 nurses (77.5%) reported believing that patients wishes were either not adequately respected or received little respect. Of these, the narratives of the 845 who indicated a reason for these beliefs and described specific experiences were included in the analysis. Response categories were classified under the four themes. Numbers of responses for themes and categories are presented in Table 1.
Table 1 Reasons for nurses feeling that patients wishes were not adequately respected or received little respect (n /845)
Theme Patients wishes unknown No. responses 555 Category (1) Circumstances prevent patients wishes from being determined (2) Lack of information about patients wishes No. responses 480 120
315
(3) Decision-making priority 236 given to the family (4) Decisions made primarily 66 by physicians (5) Experience of settings in 26 which patients wishes were not accepted (6) Insufficient information 34 provided to patients or families about the possibility of dying (7) The role of the ICU is to save life (8) Treatment is so excessive that patients would probably not want it to be performed (9) ICU environment is inappropriate for dying 98 112 13
207
243
(10) Patients have strong 56 expectations of recovery and are not mentally prepared to die (11) The patients undergo such 22 changes in appearance that they probably would not wish to be treated (12) Sudden death and time 188 constraints
657
The results of classification by theme and category, a summary of these results, and specific examples of narratives in each category are provided below.
658
S Kinoshita
/ It was mentioned that, even though many people do not wish to have their life prolonged, their families do. / One respondent described a case in which the familys wishes were given precedence even though those of the patient were known, and the patient was treated to the fullest extent possible. / Also mentioned were cases in which patients were treated aggressively if the family so desired, but in the end this prolonged patients suffering. . Decisions made primarily by physicians: Many nurses described having doubts about life-prolonging treatment prescribed by physicians. / Cases were mentioned in which the familys desire not to perform life-prolonging treatment was ignored and such treatment was continued after just a word from the physician. / Also described were cases in which the treatment plan seemed to be changed freely as a result of the informed consent practices of physicians. / Respondents described thinking that treatment was provided only to prolong patients life for the satisfaction of the physicians, and that many physicians did not halt treatment even though its effective limits had been reached. . Experience of settings in which patients wishes were not accepted: Actual experiences were described in which the manner of dying was contrary to patients wishes, although it was not clearly indicated by whose wishes those circumstances came about. / A respondent described a case in which the family of a patient who had expressed a wish to die at home on the tatami (floor mats; equivalent to being in their own bed) called an ambulance when the patient experienced cardiac arrest, and the patient was treated and admitted to the ICU. The respondent noted that, currently, if patients undergo emergency transport, their wishes are ignored and they are given lifesaving treatment. / A nurse mentioned that some elderly patients and individuals who had attempted suicide had expressed a wish to die but had been given aggressive treatment anyway. / One person described a patient saying that she wanted to go home and asked to be sent home regardless of the consequences, but her wishes could not be accommodated. / A patient who had asked before surgery not to be given life-prolonging treatment took a sudden turn for the worse, and treatment was given priority over the patients wishes. . Insufficient information provided to patients or families about the possibility of dying: Many respondents described having doubts about the adequacy of information provided to patients and their families before and during ICU admission. / Some nurses remarked that present communication and discussion levels were inadequate for end-of-life decision making by patients. / In some cases, there was no preoperative discussion about the possibility of dying. / Some respondents believed that insufficient information is provided about prognosis during the consent process, and that families believe that patients wish to recover and accordingly consent to life-prolonging treatment. However, these patients condition is severe and nothing can be done.
659
660
S Kinoshita
/ A nurse described a situation in which a patient with end-stage uterine cancer who required dialysis was admitted to the ICU. Various problems emerged and she died in the ICU. The patient had little contact with the outside world and lived a restricted life, leading the respondent to conclude that an environment should be created that enables patients to die in a befitting manner.
Other themes
Other reasons were indicated by 28 respondents, leading to the emergence of further themes: lack of opportunity to discuss death in ICUs (approach to dying) and respondents perceptions that they lacked skills in terminal care.
661
Discussion
These results revealed that the ICU nurses believed that patients wishes were not being respected, mostly owing to the following reasons: Circumstances prevent patients wishes from being determined; Decision-making priority given to the family; Sudden death and time constraints; Lack of information about patients wishes; and Treatment is so excessive that patients would probably not want it to be performed. These categories and the nurses many written statements are discussed below. With regard to Circumstances prevent patients wishes from being determined, the statements included: I cannot ascertain patients wishes if they are unconscious, and patients wishes will unavoidably not be respected, but many statements indicated a struggle, such as: I cannot ascertain their wishes, and I struggle to respect their wishes and question the treatments provided. I am concerned that patients wishes are not being respected. Thus, some of the nurses thought that an inability to respect patients wishes was unavoidable, while others struggled to respect patients wishes. The existence of these two disparate groups makes a general consensus difficult to reach. Concerning the Lack of information about patients wishes, the nurses statements suggest that, because unconscious people cannot express their desires, patients need to make their wishes for end-of-life care known while they are in other wards, and wards and ICUs must exchange information. Instead of simply giving up on respecting patients wishes when they are unconscious, a collaborative system should be established in which these wishes can be openly discussed among different hospital departments. The category Decision-making priority given to the family achieved the second highest number of responses, revealing that, in many cases, treatments are provided until the time that family members can accept the death of their relative, and that many nurses question whether family members wishes reflect patients wishes. Oberle and Hughes20 stated:
When the patient was without voice, it was generally expected that the family would guide the decisions, acting in the best interests of the patient. However, concerns were expressed that families did not always appreciate the implications of continued treatment and sometimes acted in their own best interests rather than those of the patient.
However, families naturally wish for their loved ones to live as long as possible and nurses face a dilemma in that they cannot ignore the wishes of family members. Many nurses also described experiences in which, even when patients had signed a DNR order, ongoing therapy was provided. The reasons for not respecting patients wishes thus include not only ignorance of their wishes but also difficulties in accepting DNR orders. In Japan, family members wishes have historically been respected and current organ transplantation laws necessitate family consent. Several recent cases of physician-assisted death have been described in Japan and the importance of patients wishes and their autonomy is recognized,21 but the main emphasis remains on the wishes of family members. Oberle and Hughes20 conducted interviews to investigate physicians and nurses perceptions of ethical problems in end-of-life care. The fact that doctors are responsible for making decisions and nurses must live with these decisions affects the perception of moral conflicts. In the current study, the nurses expressed opinions such as: Treatment is so excessive that patients would probably not want it to be performed, Decisions are
662
S Kinoshita
made primarily by physicians, and Insufficient information was provided to patients or families about the possibility of dying, suggesting that Japanese nurses also believe that doctors make therapeutic decisions without involving nurses. These nurses thus questioned the practice of not providing sufficient information to patients and performing excessive life-prolonging procedures, but they appear to perceive these problems as being attributable to physicians, not to nurses. Although physicians are ultimately responsible for therapeutic decision making, from patients perspective, investigating how not only patients and family members but also nurses can become involved in the therapeutic decision-making process is important. Urakawa et al.22 investigated the ethical dilemmas concerning self-determination as experienced by Japanese ICU nurses and documented the following factors: Insufficient informed consent; Circumstances in which the treatment and care provided differed from patients wishes; Circumstances in which patients wishes were unknown; and Circumstances in which judgments by family members were prioritized. Although the present results were similar, the characteristics of death in an ICU, such as sudden death and time constraints play an important role in nurses perceptions that patients wishes are not respected. Regardless of what patients desire, in the case of sudden death, insufficient time is available to respect or think about a patients wishes or to communicate with the patient or family members. Subsequently, nurses perceive that end-of-life care is insufficient. Whether or not patients are in an ICU, when conditions exacerbate quickly, how care is provided within limited time is an important issue. We do not have any control over time; solving this issue is therefore not an easy task. Many of the nurses statements suggested that treatments that seemed excessive did not respect patients wishes. Badger23 conducted a study involving ICU nurses and stated that nurses reported the most emotional distress when providing futile care, feeling that they were torturing the patient by providing aggressive care. Sawatzky7 also found that, although the death of special patients was not among the top stressors, unnecessary prolongation of life was rated highly in the frequency, intensity, and threat categories. Meltzer and Huckabay also reported the anguish experienced by nurses regarding treatment that seems not to be beneficial to patients,24 and it appears likely that similar situations occur in Japan. However, in one study, nurses were interviewed about life-prolonging procedures.14 Opinions such as although treatments are sometimes excessive, some patients are saved, and it is difficult to ascertain whether to continue therapy and, even when I know that continuing therapy will not save a patient, I understand the patients family will want the patient to live as long as possible were documented. Another point to consider is that, even if medical professionals realize that the therapy administered is excessive, treatment may be continued to avoid the risk of being sued for physician-assisted death. The Japanese Society of Intensive Care Medicine is in the process of preparing guidelines and criteria for the termination of therapy for critically ill ICU patients.25 We hope that the Society will examine closely the wishes of patients and their family members. The present results support those of previous studies: many nurses experience dilemmas and both struggle with and question their inability to respect patients wishes regarding end-of-life care. However, they also show that some nurses are rather resigned to this situation, stating that: Being unable to respect patients wishes in the ICU is unavoidable or, Physicians, not nurses, are responsible for making treatmentrelated decisions. In this investigation, some nurses considered it inevitable that ICU
663
end-of-life care is insufficient. Many appeared to hold negative opinions about studies on death in ICUs in general. Some nurses experienced difficulties and want to improve the situation, while others believe that such less than ideal situations are unavoidable in ICUs. Currently, no general consensus has been reached regarding ICU end-of-life care in Japan. One nurse wrote at the end of her questionnaire form: Every time a patient dies in the ICU, I question whether or not appropriate end-of-life care was provided. I believe that publicizing our struggle will be the first step in investigating end-of-life care in the ICU. To date, discussion about respecting patients wishes has been insufficient and nurses perspectives have yet to be clearly elucidated. Nurses play a crucial role in the decision-making process for patients and family members. In terms of respecting patients wishes it will be important to investigate not only how these wishes are handled but also how nurses interact with patients and family members and become involved in the therapeutic decision-making process together with physicians.
Conclusion
This study revealed that many ICU nurses believe that patients wishes are not respected in the process of end-of-life care in Japanese ICUs. The most commonly stated reason for this was that recognizing patients wishes is impossible, followed by the fact that decision making is performed by others regardless of whether patients wishes are known, or if there is a sudden death and attendant time constraints. Many of the narratives regarding patients wishes included doubts about whether life-saving and life-prolonging treatments should be performed or continued. These nurses also indicated that they wish to respect patients wishes regarding terminal-phase treatment but experience difficulties in doing so during ICU end-of-life care.
References
11
12 13 14 15 16 17 18 19 10
Naito Y. SIRS/MODS kanjya chiryo ni tomonau rinnritekimonndai. (Ethical problems produced by SIRS/MODS patient care.) Rinsyo Kango (Jpn J Clin Nurs) 2001; 27: 1504 /508 (in Japanese). Ishikawa M. Shi no iryo ni okeru ishiketei. (Decision-making in the medical treatment of death.) Emerg Nurs 2002; 15(8): 10 /13 (in Japanese). Anderson CA, Basteyns M. Stress and the critical care nurse reafrmed. J Nurs Adm 1981; 1: 31 /34. Huckabay L, Jagla B. Nurses stress in the intensive care unit. J Nurs Adm 1979; 9: 21 /26. Spoth R, Konewko P. Intensive care staff stressors and event changes across multiple settings and work unite. Heart Lung 1987; 16: 278 /84. Oskins SL. Identication of situational stressors and coping methods by intensive care nurses. Heart Lung 1979; 8: 953 /60. Sawatzky JV. Stress in critical care nurses: actual and perceived. Heart Lung 1996; 25: 409 /17. Erlen JA, Sereika SM. Critical care nurses, ethical decision-making and stress. J Adv Nurs 1997; 26: 953 /61. So derberg A, Norberg A. Intensive care: situations of ethical difculty. J Adv Nurs 1993; 18: 2008 /14. Hough MC. Ethical dilemmas faced by critical care nurses in clinical practice. Crit Care Clin 1996; 12: 123 /33.
664
11 12
S Kinoshita
13
14
15
16
17
18 19 20 21
22 23 24 25
Sendai T, Tanka T. ICU ni okeru do not resuscitate order (DNR). (Do not resuscitate orders (DNRs) in the ICU.) ICU to CCU (ICU and CCU) 1993; 17: 391 /97 (in Japanese). Sugawara K. Makigan kanjya no kango ni tazusawaru kangohu no jisentekitishiki. (The practical knowledge of nurses in the palliative care unit.) Kango Kenkyu (Jpn J Nurs Res) 1993; 26: 486-502 (in Japanese). Yoko K. Sinseiji no chiryo o meguru ishiketei ni kansuru rinriteki mondai to kangohu no kachikan. (Sense of values for ethical problems about decision-making, and nurse involvement in medical treatment for newborn infants.) Rinsyokango Kenkyu no Shinpo (Clin Nurs Res) 1996; 8: 91 /97 (in Japanese). Takano S. ICU deno syumatsuki niokeru kango koui,ipanbyoutou tono soui. (Nursing practice in terminal care in the intensive care unit (ICU): differences from the general ward.) Nihonrinsyoshiseigakai (Jpn Clin Thanatol) 2003; 8(1): 26 /35 (in Japanese). Keiko Y. Syuumatukiiryou niokeru ishiketeini kangofuha dou kakawateiruka. (Nurses involvement in decisions relating to terminal care.) Fukushimakenrituikadaigakukangogakubukiyou (Bull Fukushima School Nurs) 2000; 2: 1 /12 (in Japanese). Watanabe T. Jikoketei dekinai kanjyato sonokazokuno keawotooshite. (Care of patients and families who are unable to make decisions.) Shinorinsyo (Jpn J Clin Res Death Dying) 2001; 24(1): 36 /37 (in Japanese). Tateishi A, Fukumoto Y, Higashi R. Syuucyuuchiryoushisetsu nyuushitsukanjya no chiryoketeikatei no bunseki. (Analysis of the decision process in intensive care: attitudes of physicians and families when patients cannot make autonomous decisions [Abstract].) Nihon seimeirinri gakai (Jpn Bioethics Conf) 1997: 9: 36 (in Japanese). Suzaki S. Inochi haterutomo iryou ha tukimaji. (Ars longa, vita brevis.) Emerg Nurs 2002; 15(8): 19 /25 (in Japanese). Polit DF, Hungler BP. Nursing research principles and methods, third edition. Lippincott, 1987. Oberle K, Hughes D. Doctors and nurses perceptions of ethical problems in end-of-life decisions. J Adv Nurs 2001; 33: 707 /15. Hiroko S. Anrakushi, songenshi to keihou. (Euthanasia, death with dignity and criminal law.) In: Kawano T, Hirayama M eds. Rinsyoushiseigakujiten. (Dictionary of clinical thanatology.) Nihon Hyoronsya, 2000: 108 /109 (in Japanese). Urakawa K, Onishi K, Sato T, Yano K, Sato F, Nakanishi K. Ethical dilemmas faced by nurses: patient self-determination in ICU. Mie Nurs J 2004; 6: 9 /15. Badger JM. A descriptive study of coping strategies used by medical intensive care unit nurses during transitions from cure- to comfort-oriented care. Heart Lung 2004; 34: 63 /68. Meltzer LS, Huckabay LM. Critical care nurses perceptions of futile care and its effect on burnout. Am J Crit Care 2004; 13: 202 /208. Marukawa S, Maruhuji T. ICU niokeru makiiryo no konsensasu. (Consensus on terminal care in ICUs [Abstract].) (J Jpn Soc Intens Care Med) 2005; 12: 146 (in Japanese).