Intensive Care Med (2006) 32:15–17DOI 10.1007/s00134-005-2865-0 E D I T O R I A L

J. Randall CurtisSarah E. Shannon

Transcending the silos: towardan interdisciplinary approach to end-of-lifecare in the ICU

Received: 26 October 2005Accepted: 26 October 2005Published online: 16 November 2005� Springer-Verlag 2005

This editorial refers to the article http://dx.doi.org/10.1007/s00134-005-2864-1

J. R. Curtis ())Division of Pulmonary and Critical Care Medicine,Department of Medicine,University of Washington School of Medicine,Harborview Medical Center, 325 Ninth Avenue, Box 359762,Seattle, WA, 98104-2499, USAe-mail: jrc@u.washington.eduTel.: +1-206-7313356Fax: +1-206-7318584

J. R. Curtis · S. E. ShannonDepartment of Biobehavioral Nursing and Health Systems,University of Washington School of Nursing,Seattle, WA, USA

Critical care nurses play a pivotal role in end-of-life carein the ICU. They are intimately involved at all stages ofthis care, are the clinicians who spend the most time at thebedside and play key roles in communicating with fami-lies [1, 2, 3]. Prior research with family members after thedeath of a loved one in the ICU shows that families ratenurses’ skill at communication as one of the most im-portant clinical skills of ICU clinicians [4, 5]. There arealso data from the U.S. that end-of-life care in the ICU isan area where nurse-physician disagreement is common[6, 7, 8]. A study from France also suggests physiciansand nurses have very different perceptions of end-of-lifecare in the ICU [9]. In a qualitative analysis, critical carenurses expressed extreme frustration about their limitedrole in the management of patients at the end of life, usingwords like “at my institution, doctors beat patients thatGod has called” [10].

In this context, we congratulate Benishty and colleaguesfor examining the issue of nurses’ involvement in end-of-life decision-making in the ICU [11]. In this study of end-of-life care in 37 intensive care units in 17 Europeancountries, the authors asked physician-investigators theirperceptions of nurse involvement in decisions about end-of-life care in the ICU and found that physicians perceivednurses to be involved (or at least the decision was dis-cussed with them) in over three-quarters of ICU deaths.Although the primary aims of the overall study were not tostudy nurses’ involvement and although the results in thispaper are primarily based on three survey questions, thepaper provides useful insights into nurses’ involvement inend-of-life decision making. However, as the authors’ note,there is reason to suspect that nurses might have reported alower level of involvement. In fact, Ferrand and colleaguesfound in a study in France that 50% of physicians reportedthat decision making was collaborative between physiciansand nurses, whereas only 27% of nurses reported suchcollaboration [9]. Future studies should seek to examineboth the presence and the quality of collaborative decisionmaking from the perspective of all parties, includingphysicians, nurses and families.

Another interesting feature of the study by Benishtyand colleagues is the geographic variation in nurse in-volvement. Another study examined this issue in a surveyof physicians from around the world and also noted dra-matic geographic variation in the proportion of ICUphysicians reporting nurse involvement in end-of-lifedecision-making, with similar differences between north,central and south Europe [12]. Of some embarrassment toourselves, U.S. physicians reported the lowest proportionof nurse involvement of all countries represented in thisstudy. The reasons for this geographic variation are un-clear. Potential explanations include disparate views ofwhat is entailed in nurse-physician collaboration, varia-tions in nursing educational preparation or differences inthe cultural norms for health care roles in general orspecifically in end-of-life care.

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Why is this an important issue? End-of-life care inmost settings is delivered by an interdisciplinary team thatincludes nurses, physicians and other clinicians [13]. Pa-tients and families report that interdisciplinary commu-nication is a key aspect of good end-of-life care [14, 15].There is increasing emphasis on the value of interdisci-plinary teams in end-of-life care, including a call for in-terdisciplinary interventions from the 2004 National In-stitutes of Health State-of-the-Science Conference [16].Furthermore, it is likely no coincidence that most of thestudies showing that interventions can improve end-of-life care in the ICU have explicitly included an interdis-ciplinary intervention [17, 18, 19, 20, 21].

There are data from other aspects of ICU care that alsosuggest the importance of interdisciplinary communica-tion and collaboration. In several observational studies,poor interdisciplinary communication among nurses andphysicians is associated with increased mortality, lengthof stay and readmission rates [22, 23, 24, 25, 26], al-though there are also studies showing no association [27].Better nurse-physician communication has been associ-ated with enhanced professional relationships and learn-ing for nurses and physicians, as well as decreased jobstress for nurses [28, 29, 30]. Better nurse-physiciancommunication has also been associated with higher pa-tient satisfaction [31, 32, 33]. Finally, a recent Cochranereview on interventions to promote collaboration betweennurses and physicians concluded that “increasing collab-

oration improved outcomes of importance to patients andto health care managers” [34].

Formidable logistical issues confront investigators at-tempting to find ways to improve quality of care by im-proving interdisciplinary communication and collabora-tion. Despite working side-by-side toward the same goals,critical care physicians and nurses often interact onlybriefly during rounds and at the bedside of unstable pa-tients. The patient safety movement uses the metaphor ofthe silo to describe this parallel, but minimally interactivework environment. Silos are tall, windowless towers usedin agriculture to store grain or other products. ICU phy-sician and nursing cultures are often organized as silos,creating an environment where colleagues with limitedawareness of each other’s work have relatively few op-portunities for substantive communication and collabo-ration. True interdisciplinary communication and collab-oration around determining the goals of care, integratingthese goals into the treatment plans and conductingcomprehensive, consistent and sensitive communicationwith patients and their families is, in our experience, rare.Making important advances in end-of-life care for criti-cally ill patients and their families will require these twodisciplines, and the other disciplines working in the ICU,to transcend their silos and work together.

Acknowledgements Funding was provided by an R01 from theNational Institute of Nursing Research (NR-05226-01).

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