Structure and variation in end-of-life discussions in the Surgical Intensive Care Unit

The research reported here is an exploratory discourse analysis of a corpus of six end-of-life discussions in a Surgical Intensive Care Unit (SICU), describing the structure and variations of the four phases of an end-of-life discussion in terms of the function of each of these phases: the Opening (Phase 1), Description of Current Status (Phase 2), Holistic Decision Making (Phase 3), and Logistics of Dying (Phase 4). Of particular interest is Phase 2, in which the presentation of medical information culminates in an inferential summary statement that functions to establish the patient's status as terminal. We argue that it is Phase 2 that is crucial in the functional progression of an end-of-life discussion toward a decision to move from therapeutic to palliative care, since it is in Phase 2 that physicians and families interactionally achieve a consensus that allows a decision to withdraw or withhold further treatment, including life support, which would be futile and only prolong the patient's suffering. We show how two of the end-of-life discussions in the corpus that did not establish the terminal status of the patient in Phase 2 did not move to decision making in Phase 3.