Metasynthesis: Withdrawing Life-sustaining Treatments: the Experience of Family Decision-makers

Aim: The present study was undertaken to synthesise findings from qualitative investigations of family participation in decisions to withdraw and/or withhold life-sustaining treatment from a seriously ill family member.

Background: As a consequence of increasing effectiveness and sophistication of available medical interventions, death is commonly preceded by a decision to withdraw or withhold potentially life-sustaining treatments. These decisions take place in a bioethical context characterised by the pre-eminence of self-determination, but patients are typically too ill to make their own decisions. Thus, family members are called upon to participate in these morally consequential decisions on the patient's behalf.

Design: Metasynthesis.

Method: Metasynthesis is a form of inquiry that provides for integration of qualitative studies' findings to strengthen knowledge for practice and advance theoretical development. This metasynthesis was conducted using the constant comparative methods of grounded theory.

Results: Family members engage in a process of participation in decision-making that is comprised of three major categories: reframing reality, relating and integrating. Surrogates used both cues and information as they reframed their understanding of the patient's status. Relationships with providers and with other family members powerfully influenced the decision-making process. Integrating was characterised by reconciling and going forward. This part of the process has both intrapersonal and interpersonal aspects and describes how family decision-makers find meaning in their experience and move forward in their lives.

Conclusions: This synthesis provides a more comprehensive and empirically supported understanding of family members' experiences as they participate in treatment decisions for dying family members. Relevance to clinical practice. This metasynthesis provides evidence to improve family care during treatment withdrawal/withholding decision-making and a theoretical model that can be used to guide creation of clinical practice guidelines. Through increased understanding of family members' experiences, clinicians can more effectively support family decision-making processes.