INTENSIVE CARE

Being an intensive care nurse related to questions of withholding or withdrawing curative treatment
Reidun Hov
MNSc, RN, RNT

Assistant Professor, Faculty of Health Studies, Hedmark University College, Elverum, Norway also Doctoral Student, Division for Health and Caring Sciences, Karlstad University, Karlstad, Sweden

Birgitta Hedelin

PhD, RN, RNT

Adjunct Professor, Department of Nursing, Gjvik University College, Gjvik, Norway also Senior Lecturer, Division for Health and Caring Sciences, Karlstad University, Karlstad, Sweden

Elsy Athlin

PhD, RNT

Associate Professor, Division for Health and Caring Sciences, Karlstad University, Karlstad, Sweden and Faculty of Health Studies, Hedmark University College, Elverum, Norway

Submitted for publication: 12 November 2004 Accepted for publication: 26 August 2005

Correspondence: Reidun Hov Kirkeveien 48 Elverum 2418 Norway Telephone: 004762430251 E-mail: reidun.hov@hse.hihm.no or reisvein.hov@c2i.net

H O V R , H E D E L I N B , A T H L I N E ( 2 0 0 7 ) Journal of Clinical Nursing 16, 203211 Being an intensive care nurse related to questions of withholding or withdrawing curative treatment Aims and objectives. The aim of the study was to acquire a deeper understanding of what it is to be an intensive care nurse in situations related to questions of withholding or withdrawing curative treatment. Background. Nurses in intensive care units regularly face critically ill patients. Some patients do not benet from the treatment and die after days or months of apparent pain and suffering. A general trend is that withdrawal of treatment in intensive care units is increasing. Physicians are responsible for decisions concerning medical treatment, but as nurses must carry out physicians decisions, they are involved in the consequences. Design and methods. The research design was qualitative, based on interpretative phenomenology. The study was carried out at an adult intensive care unit in Norway. Data were collected by group interviews inspired by focus group methodology. Fourteen female intensive care nurses participated, divided into two groups. Colaizzis model was used in the process of analysis. Results. The analysis revealed four main themes which captured the nurses experiences: loneliness in responsibility, alternation between optimism and pessimism, uncertainty a constant shadow and professional pride despite little formal inuence. The essence of being an intensive care nurse in the care of patients when questions were raised concerning curative treatment or not, was understood as being a critical interpreter and a dedicated helper. Conclusions. The ndings underpin the important role of intensive care nurses in providing care and treatment to patients related to questions of withholding or withdrawing curative treatment.

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Relevance to clinical practice. The ndings also show the need for physicians, managers and intensive care nurses themselves to recognize the burdens intensive care nurses carry and to appreciate their knowledge as an important contribution in decision making. Key words: group interviews, intensive care nurses, interpretative phenomenology, life support care, nurses, nursing

Introduction
Nurses in intensive care units (ICUs) regularly face critically ill and injured patients. Despite often heroic efforts by the professionals to save lives, some patients do not benet from the advanced medical and technological treatment as intended. After days or months of treatment and with apparent pain and suffering, many patients die (Vincent 1999). Nurses have reported that the death process was prolonged by the use of aggressive treatment and that dying patients received invasive medical treatment immediately before death, despite evidence of their poor prognoses (Simmonds 1996, Asch et al. 1997, Seymour 2000). Furthermore, disagreement with physicians decisions, the use of advanced technology with terminally ill patients and the lack of consideration for death with dignity are themes that have been raised (Soderberg & Norberg 1993, Bunch 2001). A general trend worldwide is that withdrawal of treatment in ICUs is frequently resorted to and has increased over the past years (Prendergast 1997, McLean et al. 2000, Frde et al. 2002, Nolin & Andersson 2003). Physicians are responsible for making decisions about withholding or withdrawing curative treatment (Ministry of Health and Social Affairs 1999, Oberle & Hughes 2001) and nurses seldom participate formally in the decision-making process in spite of their comprehensive responsibility for the patients (Erlen & Frost 1991, Simmonds 1996, Viney 1996, Vincent 1999, Bunch 2000, Miller et al. 2001, Oberle & Hughes 2001, Frde et al. 2002, Ferrand et al. 2003). Nurses primary role is to nurse the patients. At the same time they must carry out physicians decisions that are sometimes perceived as contradictory to good nursing care. As shown above, many studies have been published not only regarding decisions and end-of-life care in ICUs, but also about ethical issues (Soderberg & Norberg 1993, Kuuppeloma ki & Lauri 1998, Bunch 2000, 2001). Few studies show nurses experiences of caring for dying patients in ICUs (Leino-Kilpi & Souminen 1997, Stroud 2002). No studies focusing mainly on ICU nurses experiences related to questions of withholding or withdrawing curative treatment were available. Therefore this study was conducted with the aim of acquiring a deeper understanding of what it is to be a
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nurse in these situations. This understanding might lead to ways to facilitate ICU nurses daily work when questions are raised concerning curative treatment.

Method
Design
The research design was qualitative. The approach chosen was interpretative phenomenology. In this tradition, human experiences are recognized and afrmed at the same time as the researchers presuppositions are identied and set aside as much as possible (Colaizzi 1978). Group interviews were used, inspired by focus group methodology (Morgan 1990, Benner 1994). The idea was to create a natural communicative context where peers could share experiences by talking primarily to one another and not to the researcher. A discourse of this type might remind the nurses about their experiences and trigger conrmations and contrasts that would deepen the understanding of the phenomenon (Benner 1994).

Context and participants

The study was carried out with nurses in an adult ICU in a central hospital in Norway. Altogether there were nine beds in the unit, of which six were intended for intensive care patients. Of these six, four beds were intended for patients in respirators. Some patients had a primary nurse, but primary nursing as a system was not generally carried out in the unit. The anaesthetists had the overall responsibility for medical treatment in the ICU in cooperation with the patients physician from the ordinary unit such as surgery or internal medicine. Furthermore, it was often necessary to consult other specialists. This meant that ICU nurses co-operated closely with a number of physicians. However, Norwegian ICU nurses work autonomously where basic care and carrying out medical technical treatment are concerned (Ministry of Education, Research and Church Affairs 1999). The rst author (RH) gave information about the study at a staff meeting. The head nurse then distributed written information about the study with an invitation to all 37 nurses in

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Being an intensive care nurse Table 1 Application of Colaizzis procedural steps of analysis (1978) in this study Each verbatim transcript was read to acquire a holistic understanding Signicant statements and phrases pertinent to the investigated phenomenon were extracted from each transcript Meanings from the signicant statements and phrases were formulated into themes The themes were formulated into main themes and referred back to the original transcripts for validation The results were integrated into an exhaustive description of being an ICU nurse related to questions of withholding or withdrawing curative treatment To achieve nal validation the rst author (RH) collected the nurses comments at a meeting where the ndings were discussed and conrmed

the unit to participate in group interviews. Nineteen nurses expressed an interest in participating and 14 female nurses were chosen whose time schedule permitted them to take part. The 14 nurse participants were divided into two groups, seven in each. The participants were all trained in intensive nursing care for at least 15 months, and averaged more than 10 years of experiences (225) in ICUs after specialization.

Data collection
Data were collected by focused, non-structured group interviews (cf. Morgan 1990). Each group met four times for about two hours each time, altogether 16 hours during the course of 11 weeks. The rst author (RH) was the moderator. An observer who did not belong to the research team participated to ensure that the moderator worked in accordance with the aim of the study. This observer was also responsible for audio taping. Both the moderator and the observer were registered supervisors and, therefore, familiar with group processes. The nurses were invited to the group interviews to tell about cases when decisions concerning a critically ill patients treatment turned out the way the nurses desired, when decisions did not and how they then wanted them to be. They were free to tell as many cases as they wanted. The moderator encouraged the participants to deepen their descriptions as far as possible and asked for further clarications like: How? When? In what way? What was it like? What did that mean to you? To avoid conformity to the majority opinion because of group dynamics, the moderator emphasized that no experiences were right or wrong (cf. Webb 2002). At the end of each group interview the moderator and the participants together summarized the content of the interview and agreed upon some issues for the participants to reect upon until the next interview.

Data analysis
The interviews were audio taped and transcribed verbatim by the rst author (RH). Interview data were analysed based on Colaizzis model (1978) (Table 1). Between each interview a preliminary analysis was carried out according to Colaizzis steps one to three (1978). Preliminary ndings constituted the basis for creating questions to deepen the next interview.

and current experiences about the topic. This was carried out to keep the meaning of their personal experiences separate from those revealed by the participants. After each group interview the moderator and the observer together summarized their impressions of what the participants were saying. To prevent going native (Sandelowski 1986), the moderator and the co-researchers discussed the accomplishments of each interview: Did the moderator work in a purposeful way? How was the activity in the group? Were relevant questions asked and what should be asked next time? Furthermore, credibility was enhanced by supporting ndings by quotations from the interviews and by member checking on preliminary ndings from the previous interview before starting the next interview. As recommended by Colaizzi (1978), the ICU nurses were asked to respond to how nal ndings corresponded to or differed from their experiences. The nurses conrmed all the themes and helped to clarify one theme further concerning the use of precise words to ensure correct understanding. To enhance auditability (Sandelowski 1986), Colaizzis steps of analysis (1978) were followed as precisely as possible. All transcripts with numbered statements, meanings and themes were scrutinized by two of the authors. Fittingness of data and themes was enhanced when the authors separately analysed interviews, compared clusters of themes and related them to the original transcripts. The authors also co-operated continually during the process of analysis by discussing transcripts related to statements, meanings, themes and main themes. Preliminary ndings were also discussed and conrmed by other ICU nurses (Sandelowski 1986).

Credibility, auditability and ttingness

In this study, credibility (Sandelowski 1986) was enhanced by several strategies. Prior to and during data collection, analysis and writing the authors reected on and discussed their past

Ethical considerations
Approval was obtained from the hospital director and the nursing services. The project was reported to the Norwegian
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Social Science Data Services and carried out according to International Council of Nurses codex of nursing research (Professional Ethical Guidelines and ICNs Ethical Regulation for Nurses 2001). Condentiality was assured by using numbers instead of names of patients, relatives and nurses and descriptions were made as anonymous as possible. The taped and written material was kept locked in accordance with regulations. Before each group interview a written consent was obtained from each participant, which also stated her right to refrain from participation at any time and her vow of secrecy. A contract was established with the head nurse to support the nurses if needed after the group interview.

they understood the physicians need to rest because of their tough schedule. If a nurse called, it was not always easy to make him/her understand the urgency of the situation:
I wonder how to express myself to get him out of his bed. Maybe I simply have to say: You really have to come! I will no longer have this responsibility! I have to threaten not threaten, but I have to use some effects like that. But when you know that the physician is answering the phone from his bed, you are not forceful enough even if you feel strong at some other times.

When they were on their own the nurses were afraid of missing important signs in patients which might lead to fatal consequences. It was also difcult to adequately convey to the physicians what they had observed, especially by telephone, when signs were only intuitively sensed:
Sometimes you have a vague feeling that something is wrong. And you must make the physician understand. It is difcult to nd the right words because we use all senses, but the physician, sometimes in his bed, uses only one his sense of hearing.

Findings
The analysis revealed four main themes which captured the experiences of being an ICU nurse when questions were raised related to withholding or withdrawing curative treatment: Loneliness in responsibility. Alternation between optimism and pessimism. Uncertainty a constant shadow. Professional pride despite little formal inuence. The main themes were sometimes overlapping and intertwined as they were found to be related to hospital system, patients conditions, conicts between ethical principles, the interaction between nurses and physicians and their different perspectives. The essence of being an ICU nurse in care of patients when there was a question of curative treatment or not was nally understood as being a critical interpreter and a dedicated helper.

Loneliness in responsibility
This theme was related to hospital system and interaction between physicians and nurses. Nurses daily work was based on an extended responsibility that included awareness of changes in patients conditions. This brought a feeling of professional satisfaction. When questions were raised concerning withholding or withdrawing curative treatment, the nurses perceived patients to be extremely vulnerable. Then responsibility was experienced as a burden as it was often accompanied by loneliness. Mostly the nurses felt close bonds with anaesthetists. The hospital system required that these physicians were on call at home during nights and weekends. The physicians could be called for at any time, but the nurses were reluctant to call as
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To protect patients from being harmed, the nurses felt obliged to do tasks that were the responsibility of the absent physicians. The nurses experienced this to be too much responsibility and expressed that they did not feel comfortable with it. The nurses knew that failure to act could cause prolonged suffering or death for the patient and that taking action was beyond the responsibility of a nurse. Whatever course they took, the nurses experienced it as wrong. The lack of regular meetings between physicians and nurses, or lack of conclusions in discussions about withholding or withdrawing curative treatment, also made the nurses feel alone in bearing responsibility. Even if there were discussions, they usually started accidentally and after a long time of problems. By then it was often too late because the patient was dying:
We all know that the discussion will come sooner or later, but it drags on and on. Will it be tomorrow or in a week or? Then we often ask: What now? How long? And they only say: No, lets see tomorrow. They certainly know that the treatment will be withdrawn, but we want to start the discussion earlier.

Understanding the difculties in the physicians decision making mostly steeled the nurses with patience in the face of delayed decisions. Sometimes the nurses became assertive in their behaviour towards physicians to make them take their responsibility. This was the case when physicians showed signs of giving up by not sharing plans for treatment, withdrew from patients who over time showed no progress or pushed their responsibility over to other physicians.

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Being an intensive care nurse

Alternation between optimism and pessimism

This theme was related to patients changing conditions, which meant that the daily work of the nurses was marked by irregular ups and downs between optimism and pessimism, spanning from joy to despair. When the nurses interpreted an empty look in the patients eyes or a prayer for help that could not be given, a feeling of despair occurred. A feeling of pessimism was experienced when the nurses administered treatment that violated patients dignity and caused them meaningless suffering. This occurred when patients over time became worse, showed no progress and suffered. By contrast, when patients showed recovery and when suffering was alleviated, the nurses felt relieved and hopeful. Hope and optimism were maintained when patients expressed a zest for life, wanted treatment or were expected to survive. Positive feelings were also supported when the nurses recalled previous patients who had survived against all the odds. The feeling of pessimism or optimism was easily spread among the nurses:
We are good at transmitting our own pessimism and in our ward there is sometimes a lot of pessimism aboutorSometimes I go to the nursing station and say: Give me strength to go back! I feel strengthened by just looking at the faces of my colleagues.

treatment for a single patient, general questions about life and death were often raised: Is there a limit to suffering? Can survival justify any suffering? Is it still possible for suffering patients to die a natural death in ICUs, when considering the main goal to save life? Because there were no denite answers to these questions, the nurses lived in constant ethical dilemmas between saving life and accepting a natural death, between doing good and not doing harm. Signs in patients could seldom make them sure whether the patients were really dying or had a chance of recovery. To ask the patients themselves if they wanted treatment or not was usually impossible as they were mostly unconscious, sedated or totally exhausted:
The patients are suffering and are very exhausted and then they dont really know what they say. Most of them express that they are not capable of continuing (treatment) and want to give up. So, that is why their opinions cannot be taken seriously.

Being close to the suffering of patients and relatives caused the nurses to suffer too. This led to exhaustion for some nurses, while others tried to block out their feelings:
At the same time as we face the suffering we try to roll down our blinds. It is very brutal. If I am to cope with this and not distress myself, I have to forget it.

Uncertainty also existed when goals for the patients treatment were not set, were unknown or vague, or when physicians gave conicting messages. Unclear goals made the nurses uncertain about the direction of work. The nurses felt that having clear goals would enhance the meaningfulness of their work, save their energy and make it easier for them to accept different kinds of decisions.

Professional pride despite little formal inuence

This theme was related to hospital system, different perspectives of nurses and physicians and their interaction. As they spent much time with the patients, the nurses were present when things happened and could therefore catch important signs in patients. They also made observations continuously which gave them a holistic knowledge of the patients. This was not possible for physicians, who went toand-fro. However, the nurses experienced that the physicians only occasionally listened to them despite the fact that the nurses, with their knowledge and their professional competence gained by formal training and years of experience, were able to make signicant contributions to decisions concerning patients treatment. Whether the nurses contributions were taken seriously depended on their relationship with the individual physician. The different perspectives of physicians and nurses were regarded as obstructing the exchange of information. For the nurses it was important to make the physicians understand what symptoms and suffering meant to patients and relatives. However, according to the nurses, physicians often did not care for this information because we think in different ways.

Primary nurses in particular felt distressed and hurt when nurses who went to-and-fro confronted them with distrust concerning the treatment they carried out. Nevertheless, the primary nurses usually felt more optimistic than other nurses because the closeness which the primary nurses had to their patients indeed made them vulnerable, but mostly helped them to uphold their optimism:
It is easier for those who are much together with the patient to have a positive attitude because then you see everything, all these small variations which are not easy to catch when you just drop in for some minutes.

Uncertainty a constant shadow

This theme was related to hospital system and ethical dilemmas. In addition to questions concerning if, when and why with regards to withholding or withdrawing curative

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The physicians seemed to be most interested in what other physicians said, objective signs in patients, results from laboratory tests, the law and possible legal repercussions. The nurses felt privileged to have a mandate to give crucial help. Many patients showed what was interpreted as a cry of distress which mobilized the nurses involvement to ght for them; one time to survive, another time to relieve suffering by withholding or withdrawing treatment:
Many times when I feel snowed under and everything is extremely difcult, I have thought that we are really privileged to have this kind of work. Whatever the case, whether it goes well or wrong, we have made an intense effort.

nurses or not. They felt that they were under an obligation to act according to patients best and were convinced that patients lives and deaths often depended on their presence:
It has got something to do withno matter how frustrating and hopelessif you totally disagree with the treatment, you have to do something for the patient. And that is our motive. You cannot just forget the patient and leave him and say I cant bear this any longer! because the patient is lying there, the relatives are there and you see their despair and hopelessness. You feel it, and then you have to make the best out of it, at least for their sake. You cannot give up!

As there were no formal meetings between nurses and physicians concerning important patient decisions, nurses sometimes found it necessary to attend physicians meetings and give their opinions. Sometimes they felt accepted at these meetings; at other times they felt misunderstood and hurt. Even when the nurses opinions were rejected, they were proud to have fought for what they believed was best for the patient:
It is the surgeons and the internists who are responsible for the treatment. They often show little understanding for what we see. What we nurses try to discuss is brushed aside in a way. So instead of discussing it, you are attacked and in a way you feel like a hangman and a wolf who want to kill the patient. Nevertheless, I am very pleased with what I said, but I felt so humbled.

Reections
This study was aimed at acquiring a deeper understanding of being an ICU nurse related to questions of withholding or withdrawing curative treatment. The ndings give insight into one part of ICU nurses work that is lled with paradoxes and polarities. The essence of the ICU nurse as a critical interpreter and a dedicated helper show the nurses deep concern about patients safety and well being when questions of whether or not to use curative treatment were raised. The ndings show that when the question is curative treatment or not, ICU nurses on the one hand exercise nursing autonomy, but on the other hand are controlled by the power of hospital bureaucracy and are yet dependent as physicians assistants. Because of this position, nurses have been called the people in between (Engelhardt 1985). The understanding of what it means to be in between was widened in our study as the nurses were moving between patients lives and deaths all the time. ICU nurses in-between position was closely connected to responsibility. Responsibility is one of the essential values in a caring relationship and justies the choices and actions according to accepted professional standards and moral norms (Bishop & Scudder 1990, Fry 1994, Berggren & Severinsson 2000). When it comes to questions of curative treatment, nurses are not empowered to act on the basis of their own decisions (Berggren et al. 2002). This means that they have to carry out the treatment decided by physicians, whether they agree or not and, at the same time, they are responsible for providing continuous care for patients and relatives. In our study, the responsibility for patients safety and insight into the physicians workload and heavy responsibility seemed to catch the nurses in an in-between trap. When physicians were absent the nurses carried a heavy burden that sometimes made them go beyond their own professional bounds. By doing this they covered up a decient

Being a critical interpreter and a dedicated helper

The essence of being an ICU nurse in the care of patients when questions concerning withholding or withdrawing curative treatment were in focus appeared as being a critical interpreter and a dedicated helper. The signicance of ICU nurses interpretation of the patients signs and symptoms and their commitment to the patients was prominent throughout the interviews. Due to the nurses position in the centre of the patients care, they could acquire an holistic knowledge of the patients needs, which they often considered no one else in the team had. To reach the professional goal to do good and not harm, they tried to disseminate this knowledge to the physicians, using different strategies. How the nurses interpreted the patients conditions or reactions to treatment and care and how their comprehensive picture of the patients situation was judged by the physicians, determined whether they felt lonely in responsibility or not, whether they felt pessimistic or optimistic, whether they felt uncertain or certain and whether they felt they were successful as professional

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system, took an impossible responsibility and privatized a system problem. Findings from other studies have shown that dissatisfaction with physicians treatment decisions, inappropriate formal structures and institutional guidelines are highrated stressors for nurses (Sawatzky 1996, Bucknall & Thomas 1997, Georges & Grypdonck 2002). To be in-between and to have little inuence in decision making might lead to powerlessness and ambiguity (Engelhardt 1985, Erlen & Frost 1991, Simmonds 1997). An opposite nding in our study was that nurses put themselves at risk by speaking up and taking a stand to act on professional nursing values. This behaviour is congruent with what Wurzbach (1999) described as moral certainty. However, moral certainty is not always positive as it can cause mistakes and unnecessary adverse feelings if it is not openly discussed (Wurzbach 1999). When administering treatment that caused patients what the nurses perceived as meaningless suffering, they felt they were unprofessional as they did not live up to nursing values. This nding is well in accordance with what has been found in other studies (Soderberg & Norberg 1993, Sundin-Huard & Fahy 1999, Oberle & Hughes 2001, Puntillo et al. 2001). As the perception of ones own misery might be projected to others rderud 2004), nurses own suffering and feelings of (Ska hopelessness might be perceived to be patients. This might well happen in our study as the nurses were emotionally closely linked to the patients and lacked appropriate formal forums for discussions. Such pitfalls underline the importance of time for reection and support for nurses. The nurses in our study sometimes felt misunderstood when they tried to have an open dialogue with physicians to exchange views, to have their knowledge conrmed and to state goals. Misunderstandings can lead to troublesome cooperation with physicians and have been explained by differences in the nature of work in the two professions and their different elds of knowledge (Aroskar 1985, Engelhardt 1985). It could equally well be viewed in the light of the development of the nursing profession. As the nurses in our study were highly competent in theoretical and practical ICU nursing, they considered themselves to be important contributors to physicians decisions about patients lives and deaths. But this competence might make some physicians defend their territory and not listen to the nurses as it challenged physicians traditionally powerful autocratic positions. This is in keeping with previous research (Lindahl & Sandman 1998). Recurring misunderstandings and different goals are not congruent with a good work place. Studies show that lack of collaboration is an important determinant of work-related stress to nurses and may lead to an unhealthy working environment and loss of the holistic, caring perspective of

nursing (Sawatzky 1996, Larsson 1999, Oberle & Hughes 2001, Puntillo et al. 2001, Lapsoa et al. 2003). This study clearly shows that existential questions about the meaning of suffering are almost daily companions to ICU nurses. Camus (1998) reects on the meaning of suffering in Le mythe de Sisyphe from 1942. As we know, Sisyphus was doomed to carry out a task that could never be fullled as the stone continually rushed down after his exhausting efforts to get it to the top. Camus claimed that what made the myth so tragic was that Sisyphus was conscious about his fate and had no hope of succeeding. If we relate this to the ICU nurses, they could bear suffering better when there was a hope of succeeding saving the patients lives or giving them a dignied death. Professional pride, the patients suffering and the obligation to relieve the suffering seemed to be the motivation for the nurses to continue even if they were very hard pushed.

Methodological considerations
The aim of this study was to describe a particular phenomenon and not to generalize. In this study the participants were recruited from the same unit. This makes the ndings contextual, but they were shown to be transferable to other ICU nurses experiences as they were recognized by ICU nurses in other countries and in other parts of Norway when verbally presented to them. The use of focus groups and group interviews in phenomenological research are both criticized (Webb & Kevern 2001) and advocated (Benner 1994, Haldo rsdo ttir 2000). In our study, the participants talked primarily to each other rather than to the moderator. They were active listeners, asked questions about each others experiences related to the cases and responded with similar or dissimilar cases and experiences (cf. Benner 1994). As the intention of our study was to understand a specic phenomenon, we thought that the way the group interviews were conducted led us close to the phenomenon. Conrmation, contradictions and reinforcements within the groups were not the intention, but rather personal descriptions of lived experiences. According to Morgan (1990), the more homogenous a group is in terms of background and role-based perspectives, the fewer individuals are needed in group interviews. With regards to our study, this is a truth with modications, because the experiences of each participant were addressed and experiences are individual and different. In qualitative research representativeness refers to the data rather than to the subjects or settings (Sandelowski 1986). In all, 14 ICU nurses were interviewed for 16 hours altogether. This seemed to be adequate to reach the aim of the study, searching depth rather than breadth.
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Within phenomenology, member checking is both rejected (Giorgi 1994) and recommended (Colaizzi 1978). Giorgi (1994) claimed that the researcher presents the phenomenon based on data from all participants using syntheses, theories and a professional language that is unfamiliar to participants. The participants in our study were nurses who were well acquainted with the professional language used by the researcher.

their important experiences. Thanks also to the observer, Jette Foss, who supervised the moderators work throughout the interview process. We are also grateful to Professor Elisabeth Severinsson for useful ideas and comments concerning the design of the study and to Hedmark College for nancial support.

Contributions
Study design: RH, BH, EA; data collection and analysis: RH, BH, EA; manuscript preparation: RH, BH, EA.

Conclusion
This study shows that the nurses experienced their work as both rewarding and burdensome. It also shows that ICU nurses are working in the ambiguous situation in-between, and are continually witnessing suffering, unpredictability and paradoxes. This underpins the need for physicians, managers and ICU nurses themselves to recognize the burden carried by ICU nurses when questions are raised concerning curative treatment or not. The ndings also document the important role ICU nurses play in providing care and treatment to patients when questions concerning patients lives and deaths are in focus. The importance of recognizing ICU nurses knowledge as a crucial contribution in decision making seems apparent. From this study the following recommendations for practice can be made: Appropriate systems need to be established to increase the dialogue between physicians and nurses, as well as in the nursing team, with regards to the professional aspects of decisions about withholding or withdrawing curative treatment. Communication and co-operation between nurses and physicians should be carried out with mutual respect and continuity. Formal supporting strategies to sustain a healthy, collaborative work environment should be established.

References
Aroskar MA (1985) Ethical relationships between nurses and physicians: goals and realities a nursing perspective. In Caring, Curing, Coping (Bishop AH & Scudder JR eds). The University of Alabama Press, Tuscaloosa, AL, pp. 4461. Asch DA, Shea JA, Jedrziewski MK & Bosk CL (1997) The limits of suffering: critical care nurses views of hospital care at the end of life. Social Science & Medicine 45, 16611668. Benner P (1994) The tradition and skill of interpretive phenomenology in studying health, illness and caring practices. In Interpretive Phenomenology. Embodiment, Caring and Ethics in Health and Illness (Benner P ed.). Sage Publications, Thousand Oaks, CA, pp. 99127. Berggren I & Severinsson E (2000) The influence of clinical supervision on nurses moral decision making. Nursing Ethics 7, 124133. Berggren I, Begat I & Severinsson E (2002) Australian clinical nurse supervisors ethical decision-making style. Nursing & Health Sciences 4, 1523. Bishop AH & Scudder JR (1990) The Practical, Moral, and Personal Sense of Nursing: A Phenomenological Philosophy of Practice. State University of New York Press, Albany, NY. Bucknall T & Thomas S (1997) Nurses reflections on problems associated with decision-making in critical care settings. Journal of Advanced Nursing 25, 229237. Bunch EH (2000) Delayed clarification: information, clarification and ethical decisions in critical care in Norway. Journal of Advanced Nursing 32, 14851491. Bunch EH (2001) Hidden and emerging drama in a Norwegian critical care unit: ethical dilemmas in the context of ambiguity. Nursing Ethics 8, 5767. Camus A (1998) The Myth of Sisyphus (in Norwegian). JW Cappelen, Oslo. Colaizzi P (1978) Psychological research as the phenomenologist views it. In ExistentialPhenomenological Alternatives for Psychology (Valle RS & King M eds). Oxford University Press, New York, NY, pp. 4871. Engelhardt HTJ (1985) Physicians, patients, health care institutions and the people in between: nurses. In Caring, Curing, Coping. Nurse Physician Patient Relationships (Bishop AH & Scudder JR eds). The University of Alabama Press, Tuscaloosa, Alabama, USA, pp. 6279. Erlen JA & Frost B (1991) Nurses perceptions of powerlessness in influencing ethical decisions. Western Journal of Nursing Research 13, 397407.

Further research
It would be interesting to investigate further what challenges nurses face to give good nursing care and what kind of support they might need with regards to questions of withholding or withdrawing curative medical treatment. A topic for research might also be how to build successful teams in ICUs. Furthermore, it would be interesting to investigate the same phenomenon in another context.

Acknowledgements
The authors are grateful to the heads of the hospital and especially to the ICU nurses who participated and shared
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