What does it mean to die a bad death? Provider perspectives in the surgical intensive care unit

Prior studies demonstrate that both surgeons and nonsurgeons support limiting nonbeneficial care for critically ill patients and that providers define a good death as one that is pain-free, occurs on one's own terms, and is peaceful. Despite these positions among providers, some patients still experience burdensome deaths. We sought to better understand the disconnect between provider beliefs about optimal care and actual care delivered.

We conducted semistructured interviews focused on end-of-life care with surgical intensive care unit providers including trainees, advanced practice providers, and physicians (n = 46) across 14 Veterans Affairs facilities from April 2021 to March 2022. Interview data were analyzed iteratively through steps informed by thematic analysis.

We identified 4 distinct themes among provider perspectives: poor symptom management (ie, care that led to pain, suffering, and/or loss of dignity); nonbeneficial care (ie, care that was perceived as futile or led to unnecessarily prolonged suffering); poor communication (ie, lack of timely, thorough discussions between care teams and patients or families that resulted in misinformation and lack of understanding); and lack of closure and preparation for death (ie, unresolved emotional or practical concerns).

Intensive care unit providers identified several actionable factors contributing to bad deaths, many of which can be addressed through enhanced communication and better use of existing hospital resources. Early communication with patients and families is critical to managing expectations and avoiding unnecessary treatments. Clinician training in primary palliative care and systematic implementation of discussions of goals of care may help improve the patient's end-of-life experience.