The process used by surrogate decision makers to withhold and withdraw life-sustaining measures in an intensive care environment

Purpose/Objectives: To understand the process used by surrogate decision makers who have chosen to withhold and withdraw life-sustaining measures in intensive care units (ICUs). Design: Grounded theory. Setting: Multihospital system in central Texas. Sample: 17 surrogates who decided to withhold and withdraw life-sustaining measures from patients with a variety of diagnoses, including cancer. Methods: Surrogates were identified by review of charts of patients in ICUs. Interviews were recorded on audiotape and analyzed using the process of constant comparison. Saturation of data occurred when no new themes emerged. Main Research Variable: The surrogate decision-making process. Findings: Domains and their respective themes included: (a) the personal domain: rallying family support, evaluating the patient's past and present condition, and viewing past and future quality of life; (b) the ICU environment domain: chasing doctors, developing relationships with the healthcare team, and confirming probable medical outcomes; and (c) the decision domain: arriving at a new belief, getting alone to make the decision, and communicating the decision. Conclusions: Surrogates use a definite process to make decisions regarding withholding and withdrawing life-sustaining measures for patients in ICUs. Implications for Nursing: The results reveal opportunities for healthcare providers to improve education and change practice when supporting surrogates. Additional opportunities exist for further research to expand nursing knowledge related to end-of-life issues.