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The experiences of intensive care unit nurses providing care to the brain dead patient Borozny, Margaret 1990

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THE EXPERIENCES OF INTENSIVE CARE UNIT NURSES PROVIDING CARE TO THE BRAIN DEAD PATIENT  By  MARGARET BOROZNY B.S.N., The U n i v e r s i t y  A THESIS SUBMITTED  of B r i t i s h  Columbia,  1974  IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR  THE DEGREE OF MASTER OF SCIENCE IN NURSING in FACULTY OF GRADUATE STUDIES The S c h o o l o f N u r s i n g  We a c c e p t  this  t h e s i s as  to the r e q u i r e d  conforming  standard  THE UNIVERSITY OF B R I T I S H COLUMBIA April @ Margaret  1990  Borozny,  1990  In  presenting this  degree  at the  thesis  in  University of  partial  fulfilment  of  of  department  this or  thesis for by  his  or  scholarly purposes may be her  representatives.  permission.  of  Nursing  The University of British Columbia Vancouver, Canada  Date  DE-6 (2/88)  April  19,  1990  for  an advanced  Library shall make  it  agree that permission for extensive  It  publication of this thesis for financial gain shall not  Department  requirements  British Columbia, I agree that the  freely available for reference and study. I further copying  the  is  granted  by the  understood  that  head of copying  my or  be allowed without my written  ICU  Nurses  and  the  Brain  Dead  Patient i i  Abstract THE  EXPERIENCE  OF  INTENSIVE TO  This nurses  study  attach  to  understand  patients require of  their  constitute intensive  who  to  Data  the  of  early five  to ten  to  in The  in  a  forty  five ten  affiliations. brain  brain  brain  dead  dead  dead  pervasive the  form  former  was  care  years  of one  the  these  scarcity of to  ranged  four  had  provided  for  cared  their  represented  participant cared  care  within  from  They  be  11  with  hospital  age.  had  which  intensive  had  six  intent  considered  nurse  and  A  having between  care for  for  more  no two six  than  patients. the  and of  was  in  ages  its  the  interviews  work  unit  experience  knowledge.  Their  patients,  patients,  of  our  28  of  patients  study  with  One  dead  because  quaternary  area.  over  of  care  Because  the  who  CARE  patient.  because  subjective  through  r e l i g i o u s demoninations  Throughout the  gap  and  Vancouver  twenties  religious and  care,  dead  lived.  and  the  participants  tertiary  greater  a  on  collected  female a  this  fillful  were  Caucasian units  available  brain  class  care  intensive  used  i t is  PROVIDING  PATIENT  the  was  unique  nursing  provide  essential  a  as  NURSES  meaning  of  methodology  UNIT  DEAD  the  care  experience  information  nurses  BRAIN  describes  phenomenological to  THE  CARE  participants'  unifying  either seen  in  theme.  personal relation  or to  accounts The  dissonance  dissonance  interpersonal five  areas:  was  was seen  discord. the  ICU  Nurses  and  the  Brain  Dead  Patient i i i  participant's care and  philosophy  activities,  the  concept  transplantation,  relation  to  meeting  and the  contrast,  the  latter  families,  physicians,  Transplantation dissonance attempts  to  designating  another  nurse's  and  the as  brain  professional  the  results in  nursing,  of  occurred  Team  reduce  about  own  nursing  personal  death,  organ  the  retrieval  Organ  needs.  nurse  colleagues.  In  for  Either  form  subsequent  dissonance  by  distancing  the  of  nursing  in  and  Retrieval  d i s t r e s s and  target  nursing  responsibilities  emotional  between  Pacific  traditional  and/or  care.  of  ICU  Nurses  and t h e B r a i n  Dead  Patient iv  Table  of Contents  Abstract Table List  i i  of Contents  iv  of Figures  ix  Acknowledgements  x  Debbie  CHAPTER  xi  1: I N T R O D U C T I O N  Background The  1  to the Problem  Definition  of Death  Brain  Death  and Organ  Brain  Death  and C l i n i c a l  Problem  Statement  Purpose  of the Study  Conceptual Research  1 2  Transplantation Practice  4 7 .8  Framework  8  Question  Theoretical  10  and M e t h o d o l o g i c a l  Introduction Definition  Perspectives  of the Methodology  10 10  o f Terms  12  Assumption  13  Limitations  13  i  Summary  CHAPTER  3  2: REVIEW  Criteria  OF  SELECTED  14  LITERATURE  f o r Determination  of Brain  16 Death  16  ICU  The C o n c e p t u a l D i s a r r a y Health  and t h e B r a i n  Regarding Brain  Dead  21  and t h e D y i n g P a t i e n t  i n an  Intensive  Setting  The Nurse  23  and t h e B r a i n  Dead  Patient  26  Summary  CHAPTER  31  3: METHODOLOGY  Selection  33  of P a r t i c i p a n t s  Criteria Subject  Data  34  S e l e c t i o n Procedure  36  of the P a r t i c i p a n t s  and Human R i g h t s  40 f o r Data  Collection  40  Analysis  42  Summary  CHAPTER  43  4: THE PARTICIPANTS'  ACCOUNTS  45  Introduction Dissonance Care  38 39  Collection Procedure  Data  33  for Selection  Characteristics Ethics  Patient  Death by  Care P r o f e s s i o n a l s  The Nurse Care  Nurses  45  as t h e E s s e n t i a l S t r u c t u r e  to the Brain  Dead P a t i e n t  Conceptualization Validation Interpretation Personal  of P r o v i d i n g 45  of Dissonance  of the Concept and D i s c u s s i o n  Dissonance  of Dissonance of Accounts  45 48 50 51  ICU  Nurses  and t h e B r a i n  Dead  Patient vi  Philosophy Traditional Concept Organ  51  of nursing nursing  of brain  retrieval  Professional  care  55  activities  62  death  .71  and t r a n s p l a n t a t i o n  responsibility  and  personal 79  needs Interpersonal  81  Dissonance  The  nurse  and t h e f a m i l y  82  The  nurse  and t h e p h y s i c i a n  86  The  nurse  a n d t h e PORT  96  The  nurse  and h e r n u r s i n g  Personal  Team  100  colleagues  103  Distress  104  Distancing Rationale How  105  for distancing  participants describe  the process  of 106  distancing When  distancing  Designating of  Nursing  Another  occurs as the Target  recipient  Nurse  D I S C U S S I O N OF F I N D I N G S  Personal  117 119 120  Summary  5:  Nursing  112  Family  CHAPTER  of  112  Care  Transplant  I l l  D i s s o n a n c e . . .vi"  122 122  ICU  N u r s e s and t h e B r a i n  Dead  Patient vii  Interpersonal  Dissonance  132  Distancing  140  Rationale  for Distancing  141  Detachment  143  Depersonalization  147  Designating  Another  The  Family  The  Transplant  as t h e T a r g e t  as t h e R e c i p i e n t Recipient  of Nursing of Nursing  as t h e T a r g e t  Care...150 Care....152 of  Nursing  Care  153  Nursing  t h e Nurse  154  Summary  155  CHPATER 6: SUMMARY, CONCLUSIONS, AND  IMPLICATIONS FOR  NURSING Summary  158  o f t h e Study  158  Conclusions Implications  ...161 f o r Nursing  162  Implications  f o r Nursing  Practice  162  Implications  f o r Nursing  Education  166  Implications  f o r Nursing  Research  168  Summary  169  REFERENCES  171  APPENDICES  186  Appendix  A Certificate  of Approval  f o r the Study....187  ICU  Nurses  and  the B r a i n  Dead  Patient viii  Appendix  B Letter  of Information  Appendix  C Addendum  Appendix  D Consent  Form  194  Appendix  E Trigger  Questions  197  Appendix  F  to L e t t e r  Sociodemographic  of Information  Data  189 192  199  ICU  Nurses  and  the  Brain  Dead  Patient ix  List  Figure  1.  of  Figures  The  experience  of  the  brain  patient  dissonance  dead  providing  care  i s one  to  of 49  ICU  Nurses  and  the B r a i n  Dead  Patient x  Acknowledgements I who  am  indebted  shared  their  for this  of  work.  was  Their  support  colleagues. debt  thesis  overwhelming.  continued  of  To  committee  eleven  and  and  intensive  which also  with  I  friend  Finally,  a  note  assistance  of  and  f o r h i s unending  for their  a  me  deep  unit with  nurses the  appreciation  and  dedication  g r a t e f u l l y acknowledge  encouragement my  care  provided  i n t e r e s t , enthusiasm  In a d d i t i o n ,  Felix,  gratitude  encouragement.  the  experiences  material their  to  of with  family,  mentor,  faith,  I owe  a  and  special  understanding  appreciation this  friends  study.  t o my  the  and  thesis  ICU Nurses and the Brain Dead Patient xi Debbie What were you doing...out so late...and all alone? Were you drinking?...Were you on drugs? Did you even know what happened?... It is now four days since you came to our unit...head injury, unconscious, lifeless. Tonight I am your nurse...You are so young, your body so lovely, so healthy... your head so bruised. You shouldn't be here, Debbie, lying so still...so broken...You're only 19... I am so afraid...of the responsibility... of being your nurse...and of being touched by the fragile thread that is your hold on life. Can you hear me? I talk and even sing to you, in the dark as I move around . . . checking . . . charting . . . caring... Can you feel me touch you?...with my hands...with my heart... Did you see your mother?...hear her cry...Her face paled, knees buckled when she saw you. And your brother, too young to bear such grief, circled her waist with his arm and held her up. Watching and sensing anguish, I felt my heart in my mouth...saw one of my own daughters... lying . . . like you...myself in your mother's place...and I was terrified. You died soon after...I knew you would...and I felt helplessbitter . . . and then so very hopeless . . . Did it matter...what I did? that I was there?... that I cared... At home I cried...laid awake, alone at night, and wondered at the pain I felt. I thought about quitting... never going back...to face again the sorrow of such suffering. Sometimes it hurts so much to care...to reach out...I never really knew in the beginning, how much it would take to be a nurse.  Margaret Fenton, Winnipeg Manitoba [as cited in Benner, P. and Wrubel, J . , (1989), pp. 376 377]  ICU Nurses and the Brain Dead Patient 1 CHAPTER 1: INTRODUCTION Background to the Problem Advances in medicine and technology have created a new class of dead patients - the brain dead. They are cared for by nurses who were once solely concerned with the administration of care to the living and the dying. These nurses work in intensive care units where 95% of the brain death diagnoses are made (Bart, Macon, & Humphries, 1979). The care provided includes highly technical"assessment and maintenance of hemodynamic and metabolic functions and also basic nursing care measures such as hygiene, turning, suctioning, bowel and bladder care, and the support of significant others.  To the casual observer, there is little  to differentiate this care from that provided to the living. Little is known about the experience of nurses who provide this care..  Therefore, the focus of this study will be to  understand, from the perspective of the nurse, the experience of providing care to the brain dead patient. To understand the origins of the concept of brain death, it is necessary to review how death has been defined. In addition, the rationale for nursing's involvement with patients beyond their point of death can be appreciated by reviewing the relationship that exists between brain death and organ transplantation.  Finally, a look at brain death  in clinical practice can provide some insights into the significance of brain death for nurses.  ICU Nurses and the Brain Dead Patient 2 The Definition of Death The earliest clinical sign utilized for determining death was the absence of respirations (Walker, 1979). However, following Harvey's seventeenth century discovery of the circulation of the blood and Laennec's development of the stethoscope in 1819 (Lyons & Pet-rucelli, 1987), emphasis shifted to auscultation of the heart and the absence of a heart beat became an infallible sign of death (Alexander, 1980; Presidents Commission for the Study of Ethical Problems in Medicine and Behavioral Research, 1981; Selby, 1985; Walker, 1979).  Physicians and the public were  confident that death could be pronounced with certainty based on cessation of respiratory and cardiac activity. However, at the beginning of the twentieth century, the ability to artificially maintain respirations, independent of brain function, became a reality (Cushing, 1902). Over the ensuing years, advancements were seen in cardiopulmonary resuscitation, ventilators and cardiac drugs. These resuscitative techniques, which were developed to provide life support for individuals in comatose states, also permitted a growing number of patients with dead brains to exist for indefinite periods of time with beating hearts and artificially maintained respirations (Walker, 1979). This clinically induced state resulted in many bioethical questions centering on the determination of the point at which death could and should be declared.  Nevertheless,  ICU Nurses and the Brain Dead Patient 3 over the years there has been "the gradual acceptance of the proposition that the death of the brain is a necessary and sufficient condition for the death of the individual" (Lamb, 1985, p. 5). Brain Death and Organ Transplantation A technological advance in medicine which had an impact on the intensive care unit nurse and the brain dead patient was the progress made in organ transplantation. Following the first cadaver kidney transplant in 1958 (West, Kelley, Campbell, Burns-Morrison & Zimmerman, 1986), it was recognized that viable organs would have to be recovered in order for transplantation to succeed (Couch, Curran, Hyg & Moore, 1964).  The result was that a medical demand for  brain dead patients was created "so that life might be declared extinct at a time when healthy organs were being irrigated adequately" (Walker, 1979, p. 168). Not only are the brain dead recognized as an excellent source of organs but they also remain the only source of hearts, lungs, and livers and the primary source of kidneys (Youngner, Landefeld, Coulton, Juknialis & Leary, 1989). A review of transplantation statistics reflects the medical demand for brain dead patients and the resulting requirement for nurses to provide donor care.  For instance, in Canada  during 1987, there were 2912 transplants with solid organ transplants comprising 1056 of the total (Sullivan, 1988). Within the same time period, in British Columbia 135  ICU Nurses and the Brain Dead Patient 4 cadaveric transplants were done, which was an increase from the 95 cadaveric transplants of 1986 and the 34 total transplants performed in 1985 (Pacific Organ Retrieval for Transplantation, 1986; 1987).  In 1989 British Columbia's  transplantation program moved into the arena of heart, heart - lung, and liver transplantation.  These increasing figures  underlie the fact that transplantation has become the acceptable method of treatment for organ failure. Nonetheless, to save these failing organ systems in a dead patient, nurses are required to provide not only basic nursing care but also aggressive measures.  The Canadian  Nurses Association's (1988, p.14) and subsequently the Registered Nurses Association of British Columbia (1988, p. 27), in their statements on the role of nurses in organ and tissue donation, retrieval and transplantation recognize that "nurses play a key role in identifying potential donors and in caring for donors, recipients, and their families. The nursing role involves: assessment, support, counselling, teaching, coordination, referral, health maintenance, supervision, monitoring, and advocacy." Brain Death and Clinical Practice Though the case reported by Cushing (1902) involved maintenance of vital functions for only twenty-three hours, there are now a number of reports of prolonged somatic survival following brain death (Fabro, 1982; Klein, 1982; Parisi, Kim, Collins, & Hilfinger, 1982).  In one instance,  ICU Nurses and the Brain Dead Patient  5 a twenty-three year old male was subjected to mechanical ventilation and hyperalimentation and had pneumonia, sepsis, urinary-tract infection, cardiac arrhythmias, gastrointestinal-tract bleeding, and disseminated intravascular coagulation successfully treated for 112 days after being pronounced brain dead, as "the family refused to accept the patient's demise because of his age and because of strong religious beliefs" (Klein, 1982, p. 13.62). Though this case appears to be extreme, the author is aware of a similar situation where a young male who met the criteria for brain death was pronounced dead three times on four consecutive days as his family could not accept his death.  Full support of somatic functioning was maintained  during this period. When ventilatory support was finally withdrawn, the staff was accused by the patient's wife of killing him. Physician reluctance to terminate care of the brain dead, when such an action is opposed by the family, is documented in a survey of American and Canadian neurologists and neurosurgeons (Black & Zervas, 1984). Forty-seven percent of the respondents indicated they would continue ventilatory support, another 29% would declare death but continue with ventilation and only 6 % would actually cease support of vital functions. A questionnaire on brain death, which was distributed in 1986 to 126 intensive care unit nurses, who were working  ICU Nurses and the Brain Dead Patient 6 at the Vancouver General Hospital or the British Columbia's Children's Hospital, indicated 95% of the 76 respondents had provided care to a brain dead patient (Borozny, 1988). Of the respondents 93% felt that the existence of a person ends when brain functioning ceases and 95% stated brain death alone is a sufficient criterion for withdrawal of life support systems.  However, an opposing view was stated by  one nurse: "Although a person's brain is dead it's impossible to believe (for me) that this person no longer exists at all" (Borozny, 1988, p. 39). In another case known to the author, a nurse refused to discontinue mechanical ventilation of a patient who was pronounced brain dead as she felt such action would then cause his death.  The reaction of this nurse may be related  to either an inability to accept a definition of death based on the irreversible loss of brain function ora confusion about the meaning and implication of brain death. The latter has been documented in the literature (Youngner et al., 1989) and will be discussed in detail in Chapter Two. Though brain death has been the subject of much attention with regards to the medical criteria and the associated legal, moral, and religious issues, relatively little has been published about the experience of individuals involved with the brain dead. There are a few articles indicating that the public does not think of death in terms of cessation of brain function (Arnold, Zimmerman,  ICU Nurses and the Brain Dead Patient 7 & Martin, 1968; Kaufman & Lynn, 1986).  There are also  reports about the families of brain dead patients and their feelings regarding organ donation (Bartucci, 1987; Bartucci & Seller, 1986; Butcher, 1979; Christopherson & Lunde, 1971; Gideon & Taylor, 1981; Morton & Leonard, 1979). In addition, nursing responsibilities ranging from basic and intensive nursing care to identification of potential donors have been outlined (Brent, 1983; Canadian Nurses Association, 1988; Daly, 1982; Davies & Lemkie, 1987; Registered Nurses Association of British Columbia, 1988; Youngner, et al., 1985; Walker, 1985).  However, the  literature on the reactions of nurses is limited, largely anecdotal and concerned mainly with the provision of care to the small subpopulation of brain dead patients who become organ donors.1 Problem Statement Medical and technological advances have made it possible to maintain an artificial life independent of brain function.  The refusal of some families to accept the  reality of brain death, the resulting hesitancy to pronounce death and the medical demand for viable organs for transplantation have resulted in prolonged and aggressive medical and nursing management of patients who by contemporary criteria are dead.  However, there has been  1. Only ten percent or less of the total number of brain dead patients become organ donors (West, 1986; Youngner et al., 1985).  ICU Nurses and the Brain Dead Patient 8  very little research regarding the consequences for nurses of providing care which is traditionally associated with living patients to the brain dead.  Therefore, the problem  is to determine from the perspective of the nurse the meaning attached to caring for. the brain dead patient. Purpose The purpose of the study is to describe the experience of intensive care unit nurses who provide care to the brain dead patient. Conceptual Framework When nursing behaviors traditionally associated with living patients are also applied to the dead then an incongruency exists between the nurse's actions and her knowledge regarding death and her previous experiences with death.  A theoretical perspective which this researcher used  as a starting point to help explain how nurses respond to this discordant reality is cognitive dissonance theory developed by Festinger (1957; 1959). Within Festinger's theory is the belief that the individual strives for consistency or consonance within himself - between his cognitions and his behaviours. These cognitions are "any knowledge, opinion, or belief about the environment, about oneself, or about one's behavior" (Festinger, 1957, p. 3).  When any two of these cognitive  elements (ie. knowledge and behaviour) are in a relationship  ICU.Nurses and the Brain Dead Patient 9 where the obverse of one element would follow from the other, then cognitive dissonance exists (Festinger, 1957; 1959).  For instance, in the provision of care to the brain  dead, there is an inconsistency between the nurse's knowledge about life and death and her behaviour towards the patient who has complete loss of brain function. Festinger (1957) describes four situations which may lead to dissonance.  Any one or all of these may cause  dissonance for nurses when caring for the brain dead: (1) logical inconsistency (ie. treating the dead as if they were alive), (2) culture mores (ie. what is acceptable treatment of the dead), (3) one cognition being included in a more encompassing cognition (ie. I am a nurse and nurses care for the well, the sick, and the dying), and (4) past experience (ie. once a patient dies treatment ceases). The presence of the dissonance results in psychological discomfort and subsequent pressures to reduce or eliminate the dissonance (Festinger, 1957).  "The strength of the  pressures to reduce the dissonance is a function of the magnitude of the dissonance" (Festinger, 1957, p. 18). According to Festinger (1957) the physical, social or psychological reality which impinges on a person will determine the value of the cognitions and consequently the magnitude of the dissonance.  This dissonance may be reduced  by changes in behaviour, by changes of cognition, by  ICU Nurses and the Brain Dead Patient 10 exposure to new information and by the lowering in importance of the whole matter (Festinger, 1957). Intensive care unit nurses caring for the brain dead patient may experience many conflicts among their knowledge, beliefs, opinions and actions.  For example, dissonance may  arise when the nurse is expected to accept brain death as being synonymous with the death of a human being.  This is  illustrated by the nurse who refused to turn off the ventilator and by another nurse who stated "I don't believe nursing care is to be neglected when [the] patient is brain dead - comfort measures, turns, .suctioning etc. -  continue  UNTIL [the] PATIENT [is] PRONOUNCED DEAD" (Borozny, 1988, p. 40).  It is felt that Festinger's Cognitive Dissonance  Theory is relevant to this study.  Consequently, it will  provide the conceptual framework for the study. Research Question This study will seek an answer to the following question: 1. What meaning do intensive care nurses attach to their caring for the adult brain dead patient? Theoretical and Methodological Perspective Introduction of the Methodology Because qualitative methods focus on identifying, documenting and knowing the phenomena from the informant's perspective and quantitative research is oriented towards determining cause and effect (Field & Morse, 1985; Leininger, 1985), the former is the methodology of choice  ICU Nurses and the Brain Dead Patient 11 for this study.  Therefore, the research process will  involve subjective description by the participants and inductive reasoning by the researcher as opposed to the "deductive reasoning, objectivity, quasi-experiments, statistical techniques, and control" (Munhall & Oiler, 1986, p. 3) which characterize the quantitative approach to research. In the realm of qualitative research there exist a number of "descriptive analytical investigations of the world of human experience" (Field & Morse, 1985). One approach, phenomenology, has as its goal the accurate description and understanding of experience as it is lived (Anderson, 1989; Knaack, 1984; Lynch-Sauer, 1985; Oiler, 1982; Oiler, 1986; Omery, 1983).  This requires  understanding of "both the cognitive subjective perspective of the person who has the experience and the effect that perspective has on the lived experience or behaviour of the individual" (Omery, 1983).  Therefore, phenomenological  methodology is considered appropriate to answer this study's question which seeks to describe the experience of nurses caring for the brain dead patient. A fundamental feature of phenomenology is bracketing which involves the researcher explicitly stating and setting aside any preconceived notions, expectations or assumptions about the phenomena (Field & Morse, 1985; Knaack, 1984; Oiler, 1982; Oiler, 1986; Omery, 1983).  This is necessary  ICU Nurses and the Brain Dead Patient 12 in order to truly approach the phenomena wide-eyed and "to understand human experience from the individual's perspective" (Knaack, 1984). A premise of qualitative research is that "people have cognitions that help them to make sense of their world, and the researcher needs to discover and understand these cognitive world views and lifeways of humans" (Leininger, 1985, p. 6).  When these cognitions are discordant then  Festinger's theory of cognitive dissonance can assist the researcher in understanding the experience of the participants.  Therefore cognitive dissonance theory as a  conceptual framework is compatible with phenomenological methodology. Definition of Terms The following terms are defined to explain their use in the study: Brain Death - is the irreversible cessation of brain function as defined by profound coma, apnea, and the absence of brain stem reflexes when potentially reversible conditions have been excluded and an etiology capable of causing brain death has been established (Canadian Congress of Neurological Sciences, 1986; Health Services Directorate, 1986). Care - "those assistive, supportive, or facilitative acts toward or for another individual" (Leininger, 1984, p.  ICU Nurses and the Brain Dead Patient 13  4), which are normally associated with attempts to improve a human condition. Dissonance - the clashing of coexisting beliefs, perceptions, values, opinions, knowledge and actions within one's self (personal dissonance) or between one's self and another (interpersonal dissonance). Experience - the totality of feelings, beliefs, cognitions, and actions which describe how a nurse reacts to and copes with the act of providing care to a brain dead patient. Intensive Care Unit (ICU) Nurse - a registered nurse who utilizes high technology and assessment and management skills to sustain life in acutely i l l patients in an intensive care environment of a tertiary or quaternary care hospital. Meaning - the significance the nurse assigns to her feelings, beliefs, cognitions, and actions when providing care to a brain dead patient. Assumption One assumption is pertinent to this investigation.  It  is assumed that the provision of care to a brain dead patient has meaning for the intensive care unit nurse such that she would be receptive to sharing her experience. Limitations In this study the participants were drawn from two hospitals - one a tertiary care hospital and the other a  ICU Nurses and the Brain Dead Patient 14  quaternary care hospital.  Both hospitals are located within  a large metropolitan area of one western province and have the highest incidence of brain dead donors for the province. The sample therefore consists of ICU nurses who probably have greater experience with brain dead patients and who possibly might have a different perspective on brain death due to their active involvement in organ retrieval, than nurses would working in a community hospital.  In addition,  patients younger than sixteen usually are not admitted to these hospitals, therefore, the meaning the study's participants attach to caring for the brain dead patient may not represent the experience of pediatric ICU nurses. These factors pose limitations to the generalization of the study's findings. Summary This chapter has defined the problem, the purpose of the study and the research question.  The conceptual  framework guiding the study was identified.  In addition,  the methodology, which will be explained in more detail in Chapter Three, was introduced. Studying the experience of intensive care unit nurses who provide care for the brain dead patient is of importance to nursing because not only are a large percentage of ICU nurses caring for the brain dead but the nursing measures employed are those traditionally associated with life and its maintenance.  Further, the increasing medical demand for  ICU Nurses and the Brain Dead Patient 15  cadaver organ donors, the refusal of some families to accept brain death and the resulting hesitancy to pronounce death have a direct impact on the intensive care unit nurse. The following chapter will examine the literature on the criteria of brain death, the conceptualization of brain death by health care professionals, the nurse and the brain dead patient and the nurse and the dying patient in an intensive care setting.  ICU Nurses and the Brain Dead Patient 16 CHAPTER 2: REVIEW OF SELECTED LITERATURE This review of the literature pertinent to the conceptualization of the problem statement will begin with an examination of the criteria of brain death and a brief review of its conceptual disarray among health care professionals.  Anecdotal reports and studies on the  experiences of nurses caring for the brain dead patient will also be included. However, because very little published information was found on the latter, literature relevant to the more global nursing experience of caring for the dying patient in an intensive care unit will be examined.  How ICU  nurses view dying may have an impact on the meaning they attach to the care of the brain dead patient. Criteria for Determination of Brain Death The ability to artificially sustain vital functions independent of brain function coupled with the growing need for viable organs for transplantation created a major bioethical dilemma. Two concerns were central to this situation.  First, there was the possibility of  inadvertently maintaining vital functions in a corpse. Second, there was the "danger that vital organs could be taken from the unconscious, but still 'living' patient" (Law Reform Commission of Canada, 1979, p.6).  The medical  community, cognizant of the fact that the traditional criteria for determining death (absence of cardiac and respiratory functions) were obsolete, undertook steps to  ICU Nurses and the Brain Dead Patient 17 establish the diagnosis of death based on the concept of irreversible loss of brain function. The Ad Hoc Committee of the Harvard Medical School (1968), whose purpose was to "define irreversible coma as a new criterion for death" (p.85) outlined the following clinical signs as indicative of a permanently nonfunctioning brain.  In the absence of hypothermia and central nervous  system depression the patient would demonstrate: (a) unreceptivity and unresponsitivity; (b) apnea; (c) absence of all brain stem reflexes (corneal, gag, oculocephalic, oculovestibular and pupillary light) and as a rule absence of spinal cord reflexes; and (d) an isoelectric electroencephalogram (EEG) which was considered to be only of confirmatory value and not a requirement for establishing the diagnosis. All of the above had to be repeated and confirmed at least 24 hours before death was declared. During the same year the Canadian Medical Association (1968) issued a statement on death.  Three key points were  made: 1. The determination of death is the legal responsibility of the physician and should remain so.  In  situations involving transplantation, two or more physicians who are in no way concerned with the transplantation should make the decision. 2. Death is defined in terms of cerebral function.  ICU Nurses and the Brain Dead Patient 18 3. The criteria formulated by the Ad Hoc Committee of the Harvard Medical School are suggested aids to be used in determining death. The Conference of Medical Royal Colleges and Faculties of the United Kingdom (1976a, 1976b) have also endorsed brain death as the criterion for withdrawal of medical treatment.  However, they differ from the Ad Hoc Committee  in three respects.  First, the diagnosis of a disorder which  can lead to brain death has to be fully established before discontinuing treatment.  Second, though the pupillary  reaction has to be absent, the pupils do not have to be dilated.  This statement has subsequently been supported by  others (Pallis, 1982; Plum & Posner, 1980).  Third, there  must be repetition of the tests but the time interval will depend on the primary clinical condition and the course of the disease, therefore it will be a matter for medical judgment. The Canadian Congress of Neurological Sciences (1986) has prepared guidelines for the diagnosis of brain death which have been endorsed by the Canadian Neurological Society, the Canadian Neurosurgical Society, the Canadian Association for Child Neurology, the Canadian Society of Clinical Neurophysiologists and the Canadian Medical Association (Health Services Directorate, 1986). These guidelines emphasize:  ICU Nurses and the Brain Dead Patient 19 1. The etiology of brain death must be established and reversible conditions, such as hypothermia, drug intoxication, treatable metabolic disorders, shock, and nerve or muscle dysfunction due to disease or drugs, must be excluded. 2. Deep coma and unresponsiveness must exist. However, spinal reflexes may persist (Ivan, 1973; Ropper, 1984). 3. Brain stem reflexes must be absent and pupils must be midsized or larger. 4. In the presence of adequate pC02 levels (40 +_ 5 mmHg) and passive oxygenation, apnea must exist when the patient is disconnected from the ventilator for 10 minutes. 5. Reassessment is essential, however, the interval may range from 2 hours to 24 hours depending on the etiology. The determination of brain death is a clinical diagnosis (Ad Hoc Committee, 1968; Canadian Congress of Neurological Sciences, 1986; Conference of Medical Royal Colleges and Faculties in the United Kingdom, 1976a, 1976b; Health Services Directorate, 1986).  Nonetheless, special  tests, such as electroencephalography or cerebral angiography may be used to support the clinical diagnosis (Canadian Congress of Neurological Sciences, 1986). In addition to the efforts of the medical profession, the Law Reform Commission of Canada, in 1976, began an extensive research project on the protection of human life. After receiving input from private citizens, the Canadian  ICU Nurses and the Brain Dead Patient 20 Nurses Association, federal and provincial medical associations, the Canadian Bar Association and religious groups, the Law Reform Commission (1981) recommended the following amendment to the Interpretation Act: For all purposes within the jurisdiction of the Parliament of Canada, (1) a person is dead when an irreversible cessation of all that person's brain functions has occurred. (2) the irreversible cessation of brain functions can be determined by the prolonged absence of spontaneous circulatory and respiratory functions. (3) when the determination of the prolonged absence of spontaneous circulatory and respiratory functions is made impossible by the means of support, the irreversible cessation of brain functions can be determined by any means recognized by the ordinary standards of current medical practice, (p. 25) To date the recommendations of the Commission are not part of Canadian Legislation.  As health care is a matter of  provincial concern, each province, independent of the federal government, has the option to incorporate or ignore the proposals of the Law Commission. Since 1975, Manitoba has remained the only province with a statutory definition of death (Health Services Directorate 1986; Law Reform Commission, 1979).  This definition is based on the  irreversible cessation of all brain functions.  ICU Nurses and the Brain Dead Patient 21 The Conceptual Disarray Regarding Brain Death by Health Care Professionals Despite an apparent acceptance of irreversible cessation of brain function as being the criterion for determining death, a recent exploratory-descriptive study of health care professionals by Younger et al. (1989) indicates a lack of conceptual clarity regarding brain death. This study sought to determine the participants' knowledge about brain death and "underlying concepts of death - in other words, which specific qualities of brain function are considered to be so essential or fundamental that their absence is equated with the death of a patient" (Youngner et al., 1989, p.2206).  A nonprobability sample consisting of  115 physicians and 80 nurses (20 medical ICU nurses, 20 surgical ICU nurses and 40 operating room nurses) who were likely to be involved in the care of brain dead patients, their families and or the organ retrieval process were interviewed. Knowledge regarding brain death was assessed by a multiple choice factual question and two case scenarios. The question asked was "What brain functions must be lost for a patient to be declared brain dead?" (Youngner et al., 1989, p.2206).  For the case studies, respondents were asked •  whether patient A who had irreversible loss of all brain function and patient B who had irreversible loss of all cortical brain function (ie. vegetative state) were legally  ICU Nurses and the Brain Dead Patient 22 dead.  Of the 80 nurses only 48 (60%) correctly answered the  factual question, 50 (62.5%) correctly identified patient A as legally dead, and 61 (76.25%) correctly identified patient B as riot being legally dead. The respondents' personal concepts of death were elicited by asking "Leaving aside legalities, in your personal opinion, is this patient [A and B] dead?" (Youngner et al., 1989, p.2207).  When the participants indicated  patient A or patient B was, in their personal opinion dead, they were then asked "What makes this patient dead" (Youngner et al., 1989, p.2207).  If the participants  indicated they did not consider patient A or patient B dead they were asked "What functions would have to be lost for you to consider this patient dead?" (Youngner et al., 1989, p.2207).  Youngner et al. do not separate the nurses'  concepts of death from that of the physicians'.  Ninety-five  percent of the total participants personally believed patient A was dead, 38% indicated that patient B who was vegetative also was dead, 4% rejected defining death on the basis of brain function and considered both patients A and B to be alive.  However, there were a variety of reasons for  participants believing patient A or patient B was dead. These included loss of consciousness and cognition, personhood, capacity for social interaction, ability to function as a whole, and ability to regulate bodily functions (Youngner et al., 1989).  Interestingly, although  ICU Nurses and the Brain Dead Patient 23 some respondents believed that patients A and/or B were dead, they "gave explanations suggesting that they really believed the patients were still alive, eg, 'the patient's quality of life is not acceptable,' the patient is hopelessly dying,' and the brain cannot be replaced'" (Youngner, 1989, p.2207). Youngner et al. (1989) concludes that: health professionals have personal concepts of death that vary widely and are often confused and/or selfcontradictory . . . Conf usion about the real status of potential donors (ie. whether they are dead or alive) may contribute to the emotional discomfort of those who must manage them in the intensive care unit or the operating room. (p.2210) A shortcoming of Youngner's study is that it is unknown how many of the nurses have actually provided care to brain dead patients.  In addition, his study participants were  selected for their potential to become involved with organ donors, therefore, his findings and conclusions may not be generalizable to nurses who provide care to brain dead patients who do not become organ donors. The Nurse and the Dying Patient in an Intensive Care Setting It is documented that ICU nurses have difficulty accepting death (Caughill, 1976; Lippincott, 1979; Quint, 1966).  A component of Quint's (1966) exploratory  investigation of dying included determining how the social  ICU Nurses and the Brain Dead Patient 24 structure of an intensive care unit influenced the composure strategies of the nurses.  It was noted that these nurses  work in an environment where there is overpowering emphasis placed on life-sustaining measures and recovery. Consequently, they view their role as primarily being one of life saving and when death occurs they "are faced with the reality of professional failure" (Quint, 1966, p. 51).  This  failure to save a patient results in feelings of negligence and "to forestall any accusation of negligence - from themselves, other staff members, or the patient's family nurses in this setting tend to work very hard to prolong life even when these activities may be of little use" (Quint, 1966, p.53). Quint (1966) also found that though the intensive care unit nurses tended to rationalize the patient's death, they were very vulnerable to the impact of a "high social loss death", such as a young person's death, or to a lingering death or a death which is personally disturbing. In addition, if the patient has been in the unit for any period of time, the established contact with the patient and family results in "personal involvement which is intensified when the nurse learns that the patient will die" (Quint, 1966, p. 52) . Quint (1966) views dying as a passage from living to death, which may involve one or more of four transitional stages (1) certain death at known time, (2) certain death at  ICU Nurses and the Brain Dead Patient 25 unknown time, (3) uncertain death but known time, and (4) uncertain death and uncertain time.  She emphasizes that it  is not necessary to pass through each status passage. Such is the case of the individual who at the moment of being diagnosed as brain dead jumps from the category of uncertain death and uncertain time to certain death at known time. Walker (1985) suggests that it is this jump from a living being status to a brain dead status which results in a difficult psychological adjustment for the nurse as her nursing interventions which were only minutes before directed at a living being are now aimed at a "corpse being futilely and uselessly ventilated" (p. 136). Caughill (1976), reiterates much of the preceding discussion in her book which is based on anecdotal notes and findings in the literature.  In addition, she indicates that  the low patient to staff ratio and the almost continuous demand for nursing care that keeps the nurse at the bedside, fosters a close nurse-patient-family relationship. From this relationship, a growing social story evolves and the patient becomes an unique person.  Therefore, death becomes  a personal loss and a personal failure (Caughill, 1976). The above authors provide a substantial and valid body of knowledge regarding the reactions of intensive care nurses to the human experience of dying. The question still remaining is, how do ICU nurses perceive caring for a patient who is not dying but is dead?  ICU Nurses and the Brain Dead Patient 26 The Nurse and the Brain Dead Patient The literature review on nursing and the brain dead patient reveals a paucity of studies pertaining to the experience of nurses caring for these patients.  In addition  to a questionnaire on brain death (Borozny, 1988), there are three anecdotal reports (Goldsmith & Montefusco, 1985; Lippincott, 1979; Youngner et al., 1985), and one study (Sophie, Salloway, Sorock, Volek & Merkel, 1983) which focus on nursing reactions to caring for the small subgroup of brain dead patients that become organ donors. Goldsmith and Montefusco (1985) support the viewpoint that intensive care nurses have a strong commitment to saving life and regard the diagnosis of brain death as a personal and a professional failure.  They also notes that  the "nurses who care for cadaver donors receive little immediate reward and rarely see the outcome of their efforts" (Goldsmith & Montefusco, 1985, p. 24).  This  statement is supported by an ICU nurse who indicated "For us organ donation is not rewarding as our part is sending the patient to the O.R. never to return" (Borozny, 1988, p. 40). This lack of satisfaction seen in association with the care of the brain dead is viewed by Lippincott (1979) as a source of both personal and professional stress for the ICU staff.  He states also that a focus "for the management of  stress is the development of congruent personal and organizational (unit) goals" (Lippincott, 1979, p.1095).  ICU Nurses and the Brain Dead Patient 27 However, he believes that in the area of brain death and the prolonged use of life-support systems, there may be high discordance between the staff and the institution as their goals may be different.  "For example, some people ascribe  [sic ] to a sanctity of life at all costs while others advocate therapy only if intellectual capacity may be preserved" (Lippincott, 1979, p. 1095). Youngner et al. (1985) indicate that there exists a need to pay more attention to the effects that care of the brain dead donor has on the attending nurses in the ICU and the operating room. They list a number of factors which make the provision of care difficult even if the nurse on an intellectual level understands and accepts the concept of brain death.  First, the patients although dead, look alive  - they are warm, retain a healthy colour, and visceral functions continue.  Second, the same technological methods  used for the living are employed and the patient's welfare no longer provides the rationale for these aggressive measures.  As an example of the potential confusion which  may follow, Youngner, points out that if the donor has a cardiac arrest, resuscitation is considered essential, "whereas a 'do not resuscitate' order may have been written for a living patient in the next bed" (Youngner et al., 1985, p. 321).  Third, feelings of the nurses may be  exacerbated by interactions with family members, "who are often less intellectually and emotionally prepared to accept  ICU Nurses and the Brain Dead Patient 28 the finality of death in the face of so much apparent life" (Youngner et al., 1985, p. 321).  Fourth, the brain dead  donors are often the young who were in good health but became victims of sudden, unexpected accidents or medical catastrophes.  Fifth, the organ retrieval process may  represent moral problems for the nurse. As part of a descriptive study to explore the cognitive and emotional aspects on intensive care nurses of cadaver organ procurement, Sophie et al. (1983), distributed a questionnaire to 560 ICU nurses employed in 27 hospitals. Part of this survey asked the nurses to describe their feelings regarding participation in the nursing care of cadaver donors and their families.  Of the 312 nurses  (55.7%) who returned the questionnaire only 245 (78.5%) responded to this question.  Thirty-two percent of these  respondents indicated that providing care to a potential cadaver organ donor did not bother them, 25% described the care as a rewarding experience and worthwhile activity because it helped another person, 21% found the experience emotionally draining, 12% were concerned that added stress was placed on the family and 5% found the care difficult when the donor was young. One nurse who found the care did not bother her stated "I no longer think of them (potential cadaver organ donors) as people, but as objects for salvaging parts - like a junk yard of cars" (Sophie et al., 1983, p. 264).  ICU Nurses and the Brain Dead Patient 29 A major limitation of the work by Sophie and her colleagues (1983) is that only 44.3% of the respondents had actual nursing experience in the care of a potential organ donor.  Consequently, a large number of respondents who  described their feelings regarding care of the cadaver donor were not speaking from actual clinical experience. Borozny (1988) used a questionnaire with a five point Likert Scale to obtain responses to questions on brain death from intensive care nurses.  Eighty-two percent of the  respondents indicated they found caring for a brain dead patient emotionally and physically demanding, while 14% were ambivalent and 4 % did not find the provision of care emotionally or physically demanding. These findings are at variance with those of Sophie's and her colleagues, however, this is possibly due to the difference in the studies. Sophie's study focused on the care of brain dead patients who were to be organ donors, whereas, Borozny's study simply looked at the care of brain dead patients.  Perhaps nurses  view the care of the brain dead differently if organs are to be donated. In addition, Borozny's study (1988) found that 84% of the respondents stated that supporting the family and friends of the brain dead patient was more demanding than caring for the brain dead patient. comments included the following:  Some of the general  ICU  Nurses  and t h e B r a i n  Dead  Patient 30  -  I find  caring  f o r a brain  and  physically  eg.  age o f p a t i e n t ,  patient -  will  I find  that  demanding  be a  dead  depending  social  or not  to r a t i o n a l i z e  some o f t h e c a r e  we g i v e - Why? - What i s t h e p o i n t ? I r e a l i z e  so DAMN  the r e s u l t  a second  nurse  will  outcome.  a r e t i m e s when i t  be and we s t i l l  c o u l d spend  members and e x p l a i n  time  output  what  There  that  work  hard!  - Perhaps family  know t h e a c t u a l  i n QUALITY o f l i f e .  very c l e a r  and  whether  donor.  i t difficult  believe  is  i s emotionally  on c i r c u m s t a n c e s -  situation,  we c a n s a y . . . w e l l - we don't I  patient  WHY  donation.  and t h e p r o s  F a m i l y members don't  BRAIN DEATH when t h e p a t i e n t sleeping  we spend  m a i n t a i n i n g BP, t e m p e r a t u r e ,  replacements,  and t h e y  still  time  with the  so much  energy  K+ and u r i n e  and cons  of organ  seem t o u n d e r s t a n d  LOOKS  like  he i s j u s t  s e e a BP and u r i n e o u t p u t , e t c .  (p.39) Although and  this  the w r i t t e n  author  q u e s t i o n n a i r e format  to ask f o r c l a r i f i c a t i o n  the 60% r e s p o n s e the r e s p o n d e n t s and  q u e s t i o n n a i r e used  rate  understand  indicate  d i d not permit the  or e l a b o r a t i o n  ICU n u r s e s  of responses,  study  by  do have an i n t e r e s t i n  r e g a r d i n g the b r a i n  a more i n d e p t h  from  questions  and t h e g e n e r a l comments o f f e r e d  some s t r o n g f e e l i n g s  Nevertheless,  closed-ended  dead  i s required  the p e r s p e c t i v e of the nurse  patient.  to f u l l y  t h e meaning  ICU  Nurses and  the B r a i n Dead  Patient 31  attached  to c a r i n g f o r the b r a i n dead p a t i e n t .  questionnaire provided  did not  The  d i f f e r e n t i a t e between nurses who  care to b r a i n dead p a t i e n t s and  experience with these  those who  had  had  no  patients. Summary  In t h i s chapter l i t e r a t u r e conceptualization reviewed. The based on  pertinent  concerns n e c e s s i t a t i n g  The  care p r o f e s s i o n a l s  and  followed  the  l o s s of b r a i n for  by  l e g a l community  was  This was  indicating  that conceptual confusion  Literature specific  function  their recognition  outlined.  e x i s t s amongst h e a l t h care  been  the r e d e f i n i n g of death  development of the c r i t e r i a  determination of b r a i n death and health  the  of the problem statement has  the concept of i r r e v e r s i b l e  were s t a t e d .  to  by a review of a study regarding  brain  death  professionals.  to the nurse and  the dying  patient  i n an i n t e n s i v e care s e t t i n g i n d i c a t e s these nurses have difficulty and  accepting  failure.  death and  Writings  view i t as a personal  regarding  the a c t u a l experience of  nurses c a r i n g f o r a b r a i n dead p a t i e n t are scarce l a r g e l y anecdotal.  L i t t l e has  nurse's s u b j e c t i v e  perceptions  b r a i n dead  loss  and  are  been documented about of p r o v i d i n g  care to  the the  patient.  Studying the experience of p r o v i d i n g dead p a t i e n t from the  perspective  care to the  brain  of the i n t e n s i v e care u n i t  nurse i s important i n order to f i l l  a void i n our  existing  ICU  Nurses  and  the B r a i n  Dead  Patient  32  knowledge.  The  findings  may  be  useful  direction  of  education  and  developed  by  hospitals  or  also  significance  findings and  may  ongoing  have  development  transplantation  of  programs.  support by  programs  nursing  hospital  i n guiding  f o r nurses  associations. f o r the and  the  The  establishment  provincial  ICU Nurses and the Brain Dead Patient 33 CHAPTER 3: METHODOLOGY Phenomenology was the research method used for this study.  Because the intent of this research method is "to  understand the lived experience of people" (Anderson, 1989, p. 25) it was considered to be the most appropriate methodology for determining the meaning intensive care unit nurses attach to their caring for the brain dead patient. This chapter will describe the implementation of the phenomenological method for this study.  The selection of  participants, ethical considerations, data collection and analysis will also be addressed. Selection of Participants The inability of probability sampling to derive information about the meaning of a construct (Morse, 1986) and the investigator's interest in making sense of the experience of nurses caring for the brain dead patient meant that a random sample was not appropriate. Therefore, a nonprobability sample which facilitated understanding was used (Morse, 1986). Ideally, the study sample should have been drawn from a population living the experience of the phenomena under investigation (Oiler, 1982).  However, it was necessary to  relax this criterion as the number of brain dead patients at any given time is unpredictable. Therefore, for this research, the study sample included intensive care nurses who were either caring for or had cared for a brain dead  ICU Nurses and the Brain Dead Patient 34 patient.  Besides having experienced caring for the brain  dead patient, nurses who were "good informants", that is articulate, reflective, and willing to share with the interviewer were selected (Morse, 1989).  It was essential  that the informants be not only knowledgeable but also receptive in order to "maximize opportunities to obtain the most insightful data possible" (Morse, 1986, p. 183). The exact sample size was not determined before hand because in qualitative research sampling and data collection does not cease until "the theory is complete, does not have gaps, makes sense, and has been confirmed" (Morse, 1986, p. 184).  In addition, the large volume of transcribed  interviews requiring analysis of necessity limited the number of informants (Morse, 1986).  Due to an inability to  determine in advance how well the individuals could address the topic, a convenience sample of eleven ICU nurses who were available and wanted to participate in the study was obtained. Criteria for Selection Participants for this study were recruited from two hospitals (Hospital A and Hospital B) within the greater Vancouver area.  These two hospitals were selected as they  are known to have the highest number of solid organ donors within the province (Pacific Organ Retrieval for Transplantation, 1988) and therefore a substantial number of nurses caring for brain dead patients.  For the purpose of  ICU N u r s e s  and the  Brain  Dead  Patient 35  this  study,  following 1.  the  p a r t i c i p a n t s were  r e q u i r e d to  meet  the  criteria:  to  be a r e g i s t e r e d  intensive  care  nurse  unit  of  c u r r e n t l y working i n  one  of  the  the  identified  hospitals 2.  to  have  at  3.  to  have  provided care  patient The f i r s t intensive order  to  least  within  one  the  care  unit  staff  not  by e x p e r i e n c e s  tainted  The f i n a l  caring  for  y e a r was in  the  nurses  for  the  to  to  of  one,  established. background  and t o Because  this  the  not  the  is  lived  residents)  in  second findings  avoid  The time  were of  a new  obtaining  experience  of  frame of  one  had not  been  enough  unknown whether  cared for  too  far  group of the  two o r more  brain  t h a n a n u r s e who has  cared  brain  datum was  information obtained  dead  other  pressures  to  number of  However,  the  necessary  any d i f f e r e n t  no s e t  The  provide a large  a n u r s e who has is  to  experience  it  the ICU  brain  exclude  nurses,  that  dead p a t i e n t . the  one  to  sample.  related  who have  that  past  sample.  patients only  brain  ensure  distant  experience dead  student  ensure  c r i t e r i o n was  from n u r s e s  least  established  (ie.  i n c l u d e d to  at  in  year  m a i n t a i n a homogeneous was  opinions  for  last  c r i t e r i o n was  requirement  job.  y e a r work e x p e r i e n c e  from  dead p a t i e n t s included in the  was the  informants.  ICU  N u r s e s and  t h e B r a i n Dead P a t i e n t 36  Subject Selection Following  Procedure  a p p r o v a l of the U n i v e r s i t y  of  British  C o l u m b i a ' s B e h a v i o u r a l S c i e n c e s S c r e e n i n g C o m m i t t e e and  the  r e s e a r c h committees of the t a r g e t h o s p i t a l s ,  r e c r u i t m e n t of  i n f o r m a n t s began.  t h e Head  The  r e s e a r c h e r approached  of the i n t e n s i v e c a r e u n i t s of t h e i r study  q u e s t i o n s and  o f t h e s t u d y and was  At each s t a f f meeting  t h e m e t h o d o l o g y was  p r o v i d e d f o r the n u r s e s At H o s p i t a l A a l e t t e r  s t u d y and mailbox nurses  o f e a c h ICU  nurse.  was  to d i s t r i b u t e  ( s e e A p p e n d i x B.) e x p l a i n i n g t h e distributed  board.  The  letter  the  ICU  t h e Head  Nurse  A copy o f  the  i n the study.  was  At t h e r e q u e s t  o f N u r s i n g a t H o s p i t a l B an addendum t o  confidentiality  was  requested  circulated  on  also contained information  to c o n t a c t the r e s e a r c h e r i f t h e r e  of i n f o r m a t i o n which  of  the  patient  to a l l p a r t i c i p a n t s  (see  C).  Immediately  following  t h e r e s e a r c h e r was indicated  to  A t H o s p i t a l B where t h e  the l e t t e r s .  in participating  the D i r e c t o r  Appendix  Opportunity  p l a c e d i n e a c h u n i t ' s c o m m u n i c a t i o n book o r  r e g a r d i n g how interest  purpose  questions.  d i d n o t have i n d i v i d u a l m a i l b o x e s  the b u l l e t i n  letter  to r a i s e  any  the  the  explained.  r e q u e s t i n g p a r t i c i p a t i o n was  volunteered letter  to e x p l a i n the s t u d y , answer  o b t a i n p e r m i s s i o n to present  at a s t a f f meeting.  Nurses  the s t a f f  a p p r o a c h e d by  an i n t e r e s t  two  i n the s t u d y .  meeting ICU  at H o s p i t a l A  nurses  who  A r r a n g e m e n t s were made  ICU  Nurses  and t h e B r a i n  Dead  Patient 37  to  meet w i t h e a c h  study  and o b t a i n  during  consents.  nurses  from H o s p i t a l  signed  consent  staff  Hospital sixth  At  time  a desire  a week f o l l o w i n g  two  additional  two weeks  when t h e i n v e s t i g a t o r  indicated  to r e v i e w the  the i n v e s t i g a t o r  Approximately  A to c i r c u l a t e a f o l l o w  nurse  shift  At t h a t  A approached  forms.  meeting,  t h e i r next  t o be p a r t meeting  at Hospital  The Head Nurse  to  i f another  was  follow  up l e t t e r .  She i n d i c a t e d  t h e r e was  i n t e r e s t by h e r s t a f f  indicated  that  they she  discovered  not  working.  inquiries to  five  A time meeting then  was  to p a r t i c i p a t e .  Another  the i n v e s t i g a t o r ' s  pager  that  ICU n u r s e s  from  but some assumed  the Head  Hospital  findings  problem number  was  Nurse's  B indicated  a  desire  i n the study. nurse  arranged  had c o n t a c t e d t h e i n v e s t i g a t o r o f t h e s t u d y had a g r e e d f o r the f i r s t  cancelled  to contact  further  Her  too long  discussion  was  determine i f  i n the study.  W i t h i n a week f o l l o w i n g  A twelfth after  she would  or simply a  were i n t e r e s t e d  was  be i n v o l v e d  and  required  B no  was c o n t a c t e d  the s t a f f  had w a i t e d  and  of the study.  had come f o r w a r d . meeting  a f t e r the  the f i f t h  participants determine  also  r e t u r n e d t o t h e ICU a t  up l e t t e r  the s t a f f  and  word was  due t o i l l n e s s  the i n v e s t i g a t o r heard  meeting,  from  this  to p a r t i c i p a t e .  however,  of the nurse  once she was nurse.  by phone  this  who  was  better.  No  ICU  N u r s e s and t h e B r a i n  Dead  Patient 38  Characteristics All  of the P a r t i c i p a n t s  participants  ages o f twenty thirty-one  were f e m a l e .  and t h i r t y ,  eight  o f t h e n u r s e s were C a u c a s i a n  two  were b o r n  had  lived Chile  The  i n Canada.  indicated  (2),  Catholic  (2), United  Presbyterian  (1),  (1),  nursing  One p a r t i c i p a n t  of experience  ranged  nurses.  did  rotations  that  included  the  intensive  care  unit.  Two n u r s e s w i t h only  previously  thought of  nine  i n intensive worked  room.  the s t o r y . "  born  years.  follows:  (4),  Roman  of experience i n four  and twenty units. unit,  participant's  side  t o twenty  Of t h e t e n s t a f f  care  ranged  years.  Head Nurse and t h e  and she i n d i c a t e d  maybe my  sixteen  i n nursing  functioning  i n a renal  This  transplant well  from  was an A s s i s t a n t  r e m a i n d e r were s t a f f  was  and no r e l i g i o u s a s s o c i a t i o n s ( 1 ) .  y e a r s and y e a r s  kidney  i n New Z e a l a n d and  Protestant  s i x t o twenty care  of age.  the e x c e p t i o n of  t h e i r r e l i g i o n s as  years  case  years  y e a r s and a s e c o n d  Participants'  intensive  the  and w i t h  t h e ages o f  and had been i n Canada f o r t h e l a s t  Anglican  worked  forty  One was b o r n  i n Canada f o r e i g h t e e n  participants  from  were between  and f o r t y , and one was o v e r  All  in  Two were between t h e  nurses  as c h a r g e  four  nurse of  y e a r s o f e x p e r i e n c e had One n u r s e had  the o p e r a t i n g husband  room and  had a l s o  had a  " t h i s was the r e a s o n I  of the s t o r y  i s a different  side  ICU  N u r s e s and  t h e B r a i n Dead P a t i e n t 39  Seven n u r s e s s u r g i c a l areas. one  i n coronary  had  experience All  either  Of  previous experience  these  c a r e and  s e v e n two one  in isolation  had  two  year Two  i n medical  worked i n  and  total  graduates  A third  of a b a c c a l a u r e a t e n u r s i n g p r o g r a m had  switched  o c c u p a t i o n a l h e a l t h n u r s i n g program.  seminar. by had  had  attended  attended  Organ R e t r i e v a l  a one  day  after to  seminar  E a c h p a r t i c i p a n t was  attended  seminars  f o r T r a n s p l a n t a t i o n and on b r a i n  asked  f o r b e t w e e n two  to estimate  t h e number of  provided care.  p r o v i d e d c a r e f o r s i x t o t e n b r a i n dead  s i x had  cared  f o r more t h a n E t h i c s and  t e n b r a i n dead  One patients,  patients,  patients.  Human R i g h t s  Measures to a s s u r e p r o t e c t i o n of the r i g h t s of i n f o r m a n t s began when p e r m i s s i o n t o c o n d u c t sought from  the U n i v e r s i t y  of B r i t i s h  S c i e n c e s S c r e e n i n g C o m m i t t e e and the h o s p i t a l s .  To  ensure  one  death.  t o f i v e b r a i n dead  and  One  sponsored  nurse  f o u r had  an  care courses.  had  cared  year  were  b r a i n dead p a t i e n t s t o whom she had  a  an i n t e r n a t i o n a l t r a n s p l a n t  T h r e e p a r t i c i p a n t s had  the P a c i f i c  from  hospital  F i v e nurses  of i n t e n s i v e c a r e o r c r i t i c a l  participant  nurse  on a p a r t t i m e b a s i s t o w a r d s  b a c c a l a u r e a t e degree i n n u r s i n g .  graduates  One  parental nutrition.  c o l l e g e programs or t h r e e year were w o r k i n g  neurology,  i n cardiac surgery.  of t h e p a r t i c i p a n t s were d i p l o m a  programs. their  had  the  the study  was  Columbia's B e h a v i o u r a l  the r e s e a r c h committees  the p a r t i c i p a n t s '  right  to  of  ICU  N u r s e s and  the  B r a i n Dead P a t i e n t 40  informed which and  consent  explained  C)  and  an  a l l were g i v e n a l e t t e r the  intent  opportunity  concerns.  Any  addressed  immediately.  Initial  consent  participants the  study.  concerns  At  the  written  consent  consent  form  and  Morse  (1985) and  any  (see Appendixes questions  during  obtained  verbally  of  the  obtained  contained  study  to r a i s e  indicated  time  was  the  that arose  was  when t h e y  of  of i n f o r m a t i o n  the  first  (see Appendix  study  including  and  d u r a t i o n of i n t e r v i e w s , (2) a s s u r a n c e  and  t h a t o n l y anonymous q u o t e s  dead  participant without was  p e n a l t y , and  free  to withdraw  some or a l l d a t a  (5) an from  provided  The  f o r Data first  discussion  of  be  of  written Field as  being  confidentiality  used  in  indication  study  without  any  t h a t the  nurses'  indication  the  study  experiences that  time  participant or  withdraw  penalty.  Collection  four p a r t i c i p a n t s  research topic,  reviewing  with  question  t h a t the  a t any  would  the  Collection  meeting with the  The  e x p l a n a t i o n of  to r e f u s e t o answer any  Data Procedure  would  awareness about  free  formal  D).  (1) an  indicating  p a t i e n t , (4) an  was  a  in  t a p i n g of i n t e r v i e w s , number  (3) a s t a t e m e n t  the  brain  of r e s e a r c h :  purpose,  were  the  (1983) have i d e n t i f i e d  the  heighten  from  meeting  i n the  hopefully  study  a d e s i r e to p a r t i c i p a t e  essential  publication,  or  f o l l o w i n g elements which  Sweezy  conduct  the  B  involved  the w r i t t e n  ICU  Nurses  and  the B r a i n  Dead  Patient  41 consent,  answering  demographic and  place  and  questions  background  for future  events  occurred  nurses  these  were  place  and  F o r two  the telephone.  took  posed,  information  meetings.  over  steps  that  obtaining  arranging  a  participants  time  these  For the remaining  a t the time  of the  five  first  interview. All Four  participants  of the eleven  their  homes.  their  employing  nurses  had  The  t o be  All  and  remainder  that  permission during  scheduled  at the employing  The  interview  first  structured guide  i n that  the process  t o be  the s t a f f  interviews  and  conducted  in  interviewed  meetings was  the  granted  scheduled  at  head  f o r the  working  hours.  at the p a r t i c i p a n t s '  request  agency.  subsequent  open-ended  f o r the i n t e r v i e w s .  interviews  choose  At  conducted  third  the s i t e  the f i r s t  agency.  interviews  were  had  indicated  second  selected  trigger  (see Appendix  E).  ones  were  questions  semi-  were  A l l interviews  used  to  were  audio-taped. Each depth then  of  interviews. establish  selecting  a  Though  areas  depth.  with  as each  Therefore  participated  intention  for their  as e x p r e s s i v e  were  The  nurses  theoretical  nurses  experience. be  the eleven  three  that  of the researcher  sample  ability  by  needed  a l leleven  was  to  deliberately  to speak  of the informants  the others,  in initial i n -  to the were  felt  not to  the i n v e s t i g a t o r  felt  there  t o be  pursued  participants  were  i n greater interviewed  a  ICU Nurses and the Brain Dead Patient 42 second time.  Third interviews to validate the researcher's  analysis of the data were scheduled with six of the informants who could best address the experience. Ten of the initial interviews lasted from 45 to 90 minutes.  One initial interview lasted only 30 minutes. The  second interviews ranged from 30 to 90 minutes.  One of the  second interviews ended prematurely as the participant was called back to the bedside. later.  It was continued eight days  The third interviews ranged from 30 minutes to 60  minutes.  A total of 28 interviews were conducted over 17  weeks. Data analysis began with the first reading of the initial transcription and was an ongoing process throughout the data collection. Data Analysis As soon as possible following the interview each tape was transcribed verbatim. Then the tape was replayed to check the transcription for accuracy and to add notations regarding changes in voice, significant pauses and inflections (Field & Morse, 1985). The entire transcription was then read to obtain a sense of the whole (Giorgi, 1975a, 1975b; Knaack, 1984).  Next the transcript was reviewed to  highlight areas not understood or which need further elaboration (J. Anderson, personal communication, January 30, 1989).  The interview was then read more slowly to  delineate transitions in meaning (Giorgi, 1975a, 1975b;  ICU Nurses and the Brain Dead Patient 43 Knaack, 1984).  These meaning units are "intended to single  out participants' verbal productions as a significant unit of comprehension in itself" (Lofland, 1971) and must remain faithful to the original data (Knaack, 1984; Riemen, 1986). The above process was repeated for each interview and the resulting aggregate of meaning units was organized into clusters of themes (Knaack, 1984; Riemen, 1986). These themes were then referred back to the original descriptions in order to validate them and to determine the existence of any contradictory themes. The results of this analysis forms the exhaustive description of the experience of caring for the brain dead patient, which has become the statement identifying the essential structure of the phenomenon (Knaack, 1984; Riemen, 1986).  The final step was to ask six  informants if the description formulated accurately described their experience (Knaack, 1984; Riemen, 1986). Chapter Four by exploring the nurses' accounts of providing care for the brain dead patient illustrates the development of this description. Summary The phenomenological perspective of qualitative research theory guided the methodological approach for this study.  This chapter describes how that perspective was  interpreted and implemented in the selection of participants, and collection and analysis of data. Nonprobability sampling was used in order to obtain experts  ICU  Nurses  and  the Brain  Dead  Patient  44  who dead  had  lived  the experience  patient.  interviews,  and  Data  were  analysis  of providing  collected occurred  investigator's  interpretations  participants.  The  presented  results  i n the next  of  chapter.  through  f o r the  brain  in-depth  concurrently.  were this  care  validated interactive  The with s i x process  are  ICU N u r s e s  and the  Brain  Dead  Patient 45  Chapter  4:  THE PARTICIPANTS'  ACCOUNTS  Introduction The  study's  experience in  this  effort  to  the  the  meaning  meaning  brain  dissonance.  experience The  of  present  sections  as to  Conceptualization A striking accounts  is  between two  the  of  the  the  of  dead  for  Brain  in-depth  derived  throughout  unifying  the  theme i s  structure  of  one the  patient.  chapter the  will  study of  S t r u c t u r e of  Dead  nursing  participant  and the  and d i s c u s s i o n  Essential  to  experience,  essential  this  (P)  p r o v i s i o n of  This  the  presented  address  the  and w i l l the  accounts.  P r o v i d i n g Care  Patient  Dissonance  feature  of  existence  personal  Alternatively  of  dissonance  the  are  collaborative  While each  a brain  interpretation  Dissonance  a  a common theme woven  caring for  of  patient  interviews  describes  following  the  the  the  experiences.  It  conceptualization  to  patient.  of  subjective  and p a r t i c i p a n t s  account  reveals  personal  (R)  dead  the  represent  attached  dead  analysis  units  described  action.  a brain  The f i n d i n g s  a distinctive  comparative  opinion  which d e s c r i b e  between r e s e a r c h e r  provides  of  caring for  chapter.  determine care  of  findings  the of  beliefs,  a personally  individual  statements  sometimes c o n t r a d i c t s  indicating  perceptions,  held  belief,  the  participants'  or  conflict  opinions.  perception,  participant's  or  knowledge  or  ICU Nurses and the Brain Dead Patient 46 The accounts of two participants indicate a recognition of these incongruities. P. I have trouble relating the two or the family has trouble relating the two [in reference to saying the patient is dead and at the same time trying to maintain the patient's blood pressure]. P. I thought about that after I said that and I think I probably contradicted myself a little bit in there when I said that...I think a lot of times even our thinking contradicts us. Festinger (1957) describes these inconsistencies as cognitive dissonance.  He indicates that his theory of  cognitive dissonance is built upon "the notion that the human organism tries to establish internal harmony, consistency, or congruity among his opinions, attitudes, knowledge, and values.  That is, there is a drive toward  consonance among cognitions" (Festinger, 1957, p. 260). However, besides this internal or personal dissonance, the participants also describe situations where their personal beliefs, perceptions, opinions, knowledge and behaviours oppose those of individuals with whom they interact.  This lack of external harmony represents an  interpersonal form of dissonance which may occur between the nurse and the patient's family members, the physicians, the Pacific Organ Retrieval for Transplantation (PORT) Team and nursing colleagues.  Though the existence of this  interpersonal dissonance makes Festinger's concept of cognitive dissonance insufficient to describe the phenomenon  ICU  N u r s e s and  the  Brain  Dead  Patient 47  of  caring  it  does p r o v i d e  concept  for  of  described  term  dissonance  In  or  these  dissonance  remain  are as  Festinger's  to  true  further  feels  formulate to  a  the  contemplation  and  of  tones  1986,  to m u s i c r e f e r s to  that  p.  seem to c l a s h  386).  opinions, with  her  personal held  own  t h o u g h t s and  for this  and  values  the  by  w h i c h may  musical  actions  others.  study  and the  possess  knowledge and  concurrently  defined  theory  and  the  S i m i l a r l y , as  i n d i c a t e , e a c h p a r t i c i p a n t may beliefs,  that  researcher  order  in reference  combination  each o t h e r  addition,  the  required.  resolution" (Avis,  coexisting  those  patient,  a starting point.  were  transcripts  with  dead  i n d i v i d u a l experiences  "simultaneous require  brain  d i s s o n a n c e w h i c h would  conjecture The  the  clash  actions.  In  may  with  clash  Therefore,  i s derived  from  i n t e r p r e t a t i o n of  the  word. Dissonance perceptions, one's s e l f another  i s the  values, (personal  describe  close  being  emotionally  d i s s o n a n c e and the  to  nurse  knowledge and  s t r e s s which anger,  tears,  drained.  they  coexisting  dissonance).  i n terms s u c h as  being  of  d i s s o n a n c e ) or  i n personal  off",  and/or  opinions,  (interpersonal  culminates  clashing  involve  designating  being  beliefs, actions  between one's s e l f The the  participants  worn out are  distancing another  as  and  dissonance  f r u s t r a t i o n , being  Attempts  within  physically,  made to  from the  "pissed  the  and  reduce  the  patient  target  of  her  ICU  Nurses  and t h e B r a i n  Dead  Patient  48 care.  With  reason  f o r nursing  third  party  recipient is  which  schematically  Six  may  providing  care  be t h e p a t i e n t ' s  family,  the organ  herself.  that  of  thoughts  on d i s s o n a n c e  for this  to a  framework  1.  Dissonance  participated dissonance,  to a brain  of f i v e  A model  i n figure  the e s s e n t i a l  accounts  becomes t h e shifts  of the Concept  describes  longer of care  represented  confirmed  no  and t h e f o c u s  p a r t i c i p a n t s who  interviews study,  the patient  care,  or the nurse  Validation  of  the l a t t e r ,  i n the  as defined  structure  dead  for this  of the experience  patient.  The  out of the s i x p a r t i c i p a n t s as the u n i f y i n g  third  following  contain  their  theme.  P. I t h i n k t h a t d e s c r i b e s i t . T h e r e i s a c o n f l i c t t h e r e b e t w e e n w h a t y o u know l i k e l o o k i n g a f t e r t h e b o d y a n d w h e t h e r t o t a l k t o i t o r n o t . Y o u know e s p e c i a l l y t r y i n g t o t e l l t h e f a m i l y t h a t they a r e dead and they see you r u n n i n g a r o u n d l i k e a c h i c k e n .  P. I t h i n k y o u ' v e h i t t h e n a i l r i g h t o n t h e h e a d w i t h t h a t word a c t u a l l y . And w i t h t h a t d e s c r i p t i o n a n d t h a t i s j u s t a t r u e d e s c r i p t i o n a s t o how I f e e l a b o u t t h i s . . . i s c l a s h i n g f e e l i n g s a b o u t I know my r e s p o n s i b i l i t y as a nurse a t the bedside but I a l s o know my e m o t i o n a l f e e l i n g s w h i c h I t h i n k i n t h e s e s i t u a t i o n s b e c a u s e o f o u r p r o f e s s i o n y o u h a v e t o p u t on t h e b a c k b u r n e r b e c a u s e y o u h a v e a j o b t o do a n d y o u have c e r t a i n e x p e c t a t i o n s made o f y o u t h a t i n o r d e r t o be f u n c t i o n a l a n d t o be a p r o p e r m e d i c a l t e a m member i n t h i s u n i t t h a t one must d e a l w i t h t h o s e f e e l i n g s l a t e r a n d b e c a u s e t h e r e i s n ' t t i m e n o w . . . A n d p e r h a p s when y o u a r e d e s c r i b i n g t h a t p e r h a p s t h a t ' s s o r t o f been a l i t t l e b i t of the turmoil that I get i n t o at times b e c a u s e I d o n ' t f e e l t h a t I am g i v e n t h a t t i m e t o d e a l w i t h them...And I t h i n k what you a r e s a y i n g i s v e r y accurate. I t h i n k i t ' s e x c e l l e n t . . . Yeah, yeah. But t h a t i s a n e x a m p l e o f how y o u e n d up I t h i n k d e a l i n g a bit o f c l a s h w i t h t h a t because you a r e l o o k i n g a f t e r  ICU  N u r s e s and t h e B r a i n Dead  Patient 49  Figure  1:  THE EXPERIENCE OF PROVIDING CARE TO THE BRAIN DEAD PATIENT IS ONE OF DISSONANCE  PERSONAL  DISSONANCE INTERPERSONAL  PERSONAL DISTRESS  ATTEMPTS TO REDUCE DISSONANCE BY:  DISTANCING  DESIGNATING ANOTHER AS THE TARGET OF NURSING CARE  DETACHMENT  DEPERSONALIZATION  FAMILY  TRANSPLANT RECIPIENT  NURSE  ICU  N u r s e s and t h e B r a i n  Dead  Patient 50  the whole p e r s o n and t h e n nursing.  i t becomes as I s a i d  organ  P. I t ' s f a i r l y a c c u r a t e b e c a u s e i t ' s f a i r l y a c c u r a t e as f a r as t h e way t h a t I f e e l t o w a r d s i t anyway. That t h e r e i s a l o t o f c l a s h e s and how you f e e l and what i s r e q u i r e d o f you t o do i n your n u r s i n g r o l e and I t h i n k t h e r e i s a l o t o f e t h i c a l d i f f e r e n c e s . . . Yeah. I think t h a t ' s good. I t h i n k t h a t sums up how I r e a l l y f e e l about i t . I t ' s q u i t e a c c u r a t e .  P. Yeah l i k e a d i s c o r d o r some s o r t . . . Y e a h I t h i n k you've p r e t t y w e l l have g o t i t . And i t sounds you know t h a t i t c e r t a i n l y r e f l e c t s what I wanted t o s a y .  P. I t ' s t r u e b e c a u s e I mean what you say i s v e r y t r u e . Q u i t e o f t e n what you b e l i e v e i n and what you a r e f o r c e d i n t o d o i n g i s two s e p a r a t e t h i n g s . I mean I d o n ' t know i f t h e r e i s any way t o change t h a t . I t ' s s o r t of t i e d up a b i t i n t o e t h i c s and s o c i e t y ' s v a l u e s and w h a t e v e r and t h e f a c t t h a t o f t e n s o c i e t y i s n ' t aware o f what we do. So they a r e v e r y gung-ho where we s e e t h e r e a l i t y of t h e p e r s o n and where t h e y ' r e a t and know why we should stop. You know maybe t h e f a m i l y d o e s n ' t f e e l l i k e that. So t h e r e i s a l o t o f r e a s o n s why...I t h i n k i t i s v e r y r e a l b e c a u s e I mean ah I t h i n k i n a l m o s t e v e r y b o d y we d e a l w i t h you a r e g o i n g t o g e t , i n terms of our b r a i n dead p e o p l e , y o u ' r e g o i n g t o g e t some p e o p l e who a g r e e w i t h them and some p e o p l e who d o n ' t . . . I mean a s I s a y I have a l o t o f a m b i v a l e n c e f o r PORT and y e t a l o t o f p e o p l e d o n ' t . They're r e a l l y gung-ho on i t . Sure e v e r y time we're w o r k i n g you know i t does show up and i n a t t i t u d e s and b e l i e f s y s t e m s b e c a u s e we t a l k a b o u t i t you know. Interpretation This within  section w i l l  and D i s c u s s i o n  discuss  the f i n d i n g s  t h e framework o f d i s s o n a n c e .  words w i l l  be used  to present  of Accounts of the study  The p a r t i c i p a n t s ' own  t h e d a t a and b u i l d an  ICU  N u r s e s and t h e B r a i n Dead P a t i e n t 51  exhaustive  description  dissonance  i s a major  it  i s important  individual beliefs  who  finding  t o remember  t h a t each i n f o r m a n t  accounts,  i s an  p e r s p e c t i v e and s y s t e m o f  to the e x p e r i e n c e .  encounter  Although  i n the p a r t i c i p a n t s '  b r i n g s an u n i q u e  and v a l u e s  participants  of the e x p e r i e n c e .  Therefore,  t h e same i n t e r n a l  not a l l  and e x t e r n a l  discord. Personal  Dissonance  The result five of  i n personal  of care  what n u r s i n g conforms  traditional  appropriate patient? family death  i s and how to t h i s  philosophy.  The t h i r d  around  also  t o a dead  The second That  involves  i s , what i s  f o r a dead  look at n u r s i n g care of  c e n t e r s on t h e c o n c e p t to the p a r t i c i p a n t .  the nurse's  beliefs  and t r a n s p l a n t a t i o n .  professional  philosophy  of care  nursing care a c t i v i t i e s .  and i t s s i g n i f i c a n c e  nurse's  the p r o v i s i o n  will  p a t i e n t can  the p a r t i c i p a n t ' s  and i n a p p r o p r i a t e n u r s i n g c a r e  members.  retrieval  dead  o c c u r r i n g i n one o r more o f  concerns  This section  revolves  to a b r a i n  dissonance  a r e a s . The f i r s t  patient the  provision  regarding  The f i f t h  responsibilities  of b r a i n  The f o u r t h organ  focuses  and h e r own  on t h e emotional  needs. Philosophy From  of n u r s i n g .  the t r a n s c r i p t i o n s  i t i s evident  participants  personal dissonance  to  their  reconcile  personal  occurs  philosophy  t h a t f o r many  due t o an  inability  o f what n u r s i n g i s  ICU  N u r s e s and t h e B r a i n Dead P a t i e n t 52  with  the p r o v i s i o n  accounts  of care  to a b r a i n  of four p a r t i c i p a n t s  R. What does n u r s i n g mean  dead  illustrate  patient.  this  discrepancy.  t o you?  P. C a r i n g f o r p e o p l e I g u e s s t h a t a r e i l l when unable to care f o r themselves. R. And i s t h a t d i f f i c u l t b r a i n dead p a t i e n t ? P. I t s h o u l d is.  to put w i t h  be t h e same b u t I don't  R. What would  The  caring  they're  f o r the  t h i n k i t always  make i t d i f f e r e n t ?  P. Cause sometimes you t h i n k t h a t they s h o u l d be i n t h e morgue i n s t e a d o f b e i n g c a r e d f o r t h e way t h e y a r e . Within informant  this  excerpt  i s obvious  same b u t . . . "  Similar  the c o n f l i c t  i n the statement: dissonance  o c c u r r i n g w i t h i n the " I t should  i s seen  with  be t h e  other  participants. P. I would say a l l i n a l l t a k i n g c a r e o f a b r a i n dead p a t i e n t whether t h e y ' r e g o i n g t o be a donor o r n o t i s difficult. I s a y i t i s p r o b a b l y one o f t h e h a r d e s t p a t i e n t s t o t a k e c a r e o f i n ICU. They a r e s t i l l dead no m a t t e r how you l o o k a t whether t h e y a r e g o i n g t o be a donor o r whether t h e y ' r e n o t . And i f you a l l o w y o u r s e l f to t h i n k about t h a t i t ' s k i n d of creepy to t h i n k t h a t you a r e t a k i n g c a r e o f t h i s dead p a t i e n t and p e r s o n a l l y I choose to r e a l l y not t h i n k about i t . . . B u t I t h i n k i t i s a v e r y d i f f i c u l t p a t i e n t . They a r e s t i l l dead a f t e r a l l and t h a t ' s v e r y d i f f i c u l t especially when we're used t o t a k i n g c a r e o f t h e l i v i n g and we want t o , you know, b r i n g them t o t h a t p o i n t o f r e c o v e r y and I g u e s s i t j u s t goes a g a i n s t what we're s o r t o f taught. R. What do you t h i n k n u r s i n g i s ? P. W e l l , I t h i n k n u r s i n g i s t a k i n g c a r e o f t h e p a t i e n t to b r i n g them t o a h e a l t h i e r p o i n t . And I g u e s s t h a t ' s why i t goes a g a i n s t what we a r e t a u g h t i n n u r s i n g . I g u e s s t h a t ' s more i t . And we a r e d e a l i n g w i t h t r y i n g  ICU  N u r s e s and t h e B r a i n  Dead  Patient 53  to make them w h o l e . T r y i n g t o make them w e l l and you a r e i n a s i t u a t i o n where t h a t ' s n o t g o i n g t o happen. One p a r t i c i p a n t r e l a t e s n u r s i n g communicating  with  when t h e p a t i e n t communication. nurse  the p a t i e n t  i s dead  there  Communication  experiences  to her p l e a s u r e i n  and f a m i l y  members.  i s no c o r n e r  stone f o r  i s not p o s s i b l e  i n t e r n a l dissonance  However,  t h e r e f o r e the  i f nursing  continues.  P. I t h i n k I j u s t f i n d t h a t s u c h a g r e y a r e a o f n u r s i n g j u s t l o o k i n g a f t e r t h i s BODY t h a t you know t h e p e r s o n i s dead so you r e a l l y i t ' s h a r d t o i m a g i n e y o u ' r e n o t looking a f t e r a person. Y o u ' r e l o o k i n g a f t e r a body. R. What does n u r s i n g  mean  t o you then?  P. I t must have t o do w i t h t h e p e r s o n b e i n g a l i v e . I t h i n k I d e r i v e such a s a t i s f a c t i o n i n communicating w i t h t h e f a m i l y i f you c a n ' t communicate w i t h t h e patient. You know I r e a l l y e n j o y p a t i e n t s you c a n communicate w i t h so i f t h e y ' r e b r a i n i n j u r e d and t h e y ' r e n o t a b l e t o communicate w i t h you i t ' s t h e family. A f t e r t h e y ' r e b r a i n dead i t ' s no one. A number o f p a r t i c i p a n t s c a n n o t reason Their  for their  nursing  internal discord  care  perceive  of the b r a i n  i s evident  i n their  a goal or  dead  patient.  questioning.  P. So i t i s a l m o s t l i k e you know: "Why a r e we d o i n g t h i s to people? Why a r e we?" The f a m i l y i s h a v i n g t r o u b l e enough c o p i n g b u t t h e y s t i l l have hope w h i l e you're s t i l l c a r i n g f o r the person.  P. I mean you c a n no l o n g e r s u p p o r t t h e f a m i l y r e a l l y because the p a t i e n t ' s dead. You c a n ' t do a n y t h i n g f o r the p a t i e n t i f you b e l i e v e t h a t t h e p a t i e n t d i e s when t h e y ' r e b r a i n dead i f t h a t ' s what you b e l i e v e w h i c h I do. So who a r e you d o i n g t h i s f o r ? On t h e o t h e r organ  donor  this,  hand  i f the b r a i n  dead  patient  f o r some p a r t i c i p a n t s , h e l p s  becomes an  to e s t a b l i s h  ICU  N u r s e s and  the B r a i n Dead P a t i e n t 54  the  e x i s t e n c e of a g o a l f o r t h e i r  nursing  care  then  allows  care.  consonance  T h i s end  point  to  to be e s t a b l i s h e d .  P. I f t h e y ' r e a donor I t h i n k i t makes i t a l i t t l e b i t e a s i e r b e c a u s e you see an end r e s u l t to t a k i n g c a r e of a patient. However, t h i s personal  same p a r t i c i p a n t  dissonance  i f the  realized.  The  brain  p a t i e n t whose f a m i l y had  dead  donation.  But  releasing  the  situation  retrieval  t h e r e was body and  she  experiences  of organs i s not  d e s c r i b e s i n v o l v e s a young  a delay  the  also  consented  i n the  to  organ  coroner's  f a m i l y withdrew  their  office consent  for  donation. P. She was g o i n g t o be a d o n o r . They were a c t u a l l y g o i n g t o t a k e q u i t e a few o r g a n s and t h e r e was a r e a l mix up i n a l o t of t h i n g s . And I took c a r e of her f o r two days and a t the end of t h a t time t h e y d i d n ' t t a k e any o r g a n s from her a t a l l l i k e not even her e y e s . And I found t h a t p r o b a b l y the most f r u s t r a t i n g c a s e t h a t I have e v e r worked w i t h . I t h i n k p r o b a b l y the most e m o t i o n a l l y d r a i n i n g . . . I was r e a l l y f r u s t r a t e d . I was worn out p h y s i c a l l y b e c a u s e i t t a k e s a l o t o f work. You work r e a l l y h a r d when you t a k e c a r e of when you t r y and keep somebody g o i n g . And I g u e s s t h a t I j u s t t h o u g h t t h a t a l l my work was i n v a i n . T h i s was a l o t of work and I g u e s s I j u s t g e a r e d my e n e r g y t o the f a c t t h a t somebody was g o i n g t o be b e n e f i t t i n g . They were g o i n g t o t a k e a l o t of o r g a n s so I was r e a l l y w o r k i n g h a r d you know t o t h i s p o i n t and I j u s t f o u n d i t r e a l l y frustrating. I don't know i f one t h i n g t h a t r e a l l y f r u s t r a t e d me but I remember f e e l i n g r e a l l y c l o s e t o t e a r s a t the end of t h a t two day t i m e . I just felt t h a t i t was a l l i n v a i n f o r n o t h i n g and I f o u n d t h a t emotionally draining. I r e a l l y did. The  preceding  dissonance when the  and  the  transcripts resulting  individual's  incongruent  with  the  illustrate  the  personal stress  philosophy  about  personal which  occur  nursing i s  a c t of p r o v i d i n g n u r s i n g c a r e  to a  ICU  N u r s e s and  the  Brain  Dead  Patient 55  brain  dead  nursing  patient.  I f a nurse  which i n c l u d e s  of  internal  in  the  care  dissonance  following  of  possesses a philosophy the  ceases.  dead  then  Evidence  the  for  about  possibility  this  is  found  description.  P. I t h i n k t h a t n u r s i n g i s c a r i n g f o r . Is c a r i n g f o r . I t d o e s n ' t m a t t e r whether the p e r s o n . . . i f i t ' s a baby t h a t has been b o r n too e a r l y . . . f o u r months, f i v e months and has no hope of l i v i n g and i s b o r n d e a d . You would s t i l l c a r e f o r t h a t as a l i v i n g p e r s o n . T h a t ' s why we bury them. We have c e r e m o n i e s and we bury them. We t r e a t them w i t h r e v e r e n c e . We work w i t h the f a m i l y w i t h the g o a l of h e l p i n g them t h r o u g h i t . T h a t ' s nursing. So i t w o r k s . I t works f o r the whole s p e c t r u m through. N u r s i n g i s c a r i n g f o r the whole p e r s o n and the whole p e r s o n i n v o l v e s c a r i n g f o r DEATH'. Cause t h a t ' s j u s t d e a t h i s a p a r t of l i f e . It just exists. So I d o n ' t know n u r s i n g f o r me h a n d l e s the whole spectrum. I - I c a n ' t see t h a t you can s e p a r a t e i t o u t . While beliefs,  this  view  values,  behaviour,  the  did  not  opinions,  result  i n clashes  perceptions,  p a r t i c i p a n t did  of  personal  knowledge  experience  and  interpersonal  dissonance. Traditional Associated certain  clearly  patient's  cognitions  to and  providing actions  death,  the  defined and  these  the  care  provision actions  nursing  dead  behaviour  then  of  nursing  care  which  provide  for  care  and  are  so  and  activities  Though the ensuring  in opposition  behaviours  comfort  inconsistencies  occur.  f o r comfort  which a r e  activities.  psychological  traditional  administered  are  with  physical  When t h e s e  that  nursing  the  to her  deeply  are the  safety.  are  also  between  nurse  recognizes  patient's knowledge  instilled  that  safety about not  to  ICU  N u r s e s and t h e B r a i n  Dead  Patient 56  do  them may c a u s e  turmoil.  Four  p a r t i c i p a n t s address  this  issue. P. L i k e I went t h r o u g h t h e m o t i o n s b e c a u s e l i k e I c a n ' t s o r t o f I d i d n ' t q u i t e know why I was g o i n g t h r o u g h t h e motions. I t was t o o i n g r a i n e d i n me. I can only l e a v e them l y i n g so l o n g t h e n I have t o t u r n them. I have t o s u c t i o n them t o f e e l l i k e I am d o i n g .  P. I s t i l l remember we had a b r a i n dead p a t i e n t and t h i s p a t i e n t was t h e donor a l r e a d y . And we were d o i n g a l l the care f o r the donor. And I t h i n k he had an u n s t a b l e C s o m e t h i n g f r a c t u r e a s w e l l . . . a n d we were g o i n g t o l o g r o l l him and do sand bags...we were t a k i n g a l l t h i s p r e c a u t i o n s and t h e n one o f t h e n u r s e s s a i d : " W e l l you d o n ' t have t o do t h a t anymore you know b e c a u s e h e ' s dead and he d o e s n ' t f e e l i t and i t d o e s n ' t m a t t e r i f t h e bone g e t s d i s l o c a t e d o r w h a t e v e r . " But i t was a r e a l l y w e i r d f e e l i n g b e c a u s e a l l your t r a i n i n g and a l l your t h i n g i s t o p r e v e n t any f u r t h e r i n j u r y t o the p a t i e n t . And a t t h a t p o i n t you go "Oh yeah, right." But i t ' s j u s t h a r d e r b e c a u s e i t ' s n o t what y o u ' r e used t o d o i n g .  P. I t h i n k i t ' s a v e r y d i f f i c u l t s i t u a t i o n . . . L i k e we a r e so g e a r e d i n ICU I t h i n k t o d o i n g our l i t t l e tasks and I t h i n k a l o t o f t i m e s even our t h i n k i n g c o n t r a d i c t s u s . And you have t o have a l o t o f e x p e r i e n c e and maybe s o r t o u t your f e e l i n g s and why you do t h i n g s and t h a t t a k e s a w h i l e . You d o n ' t c a l l them by name y e t y o u ' r e so used t o d o i n g t h e s e l i t t l e tasks t h a t you do them anyway. And you know t h e y ' r e dead and y e t t h e r e i s s o m e t h i n g w i t h i n you t h a t d r i v e s you t o t a k e c a r e o f t h i s p e r s o n c a u s e t h e y a r e s t i l l i n your c a r e and r e a l l y when you t h i n k o f i t i t makes no s e n s e . T h i s p a t i e n t i s a dead p a t i e n t and why a r e we d o i n g this? Sometimes I t h i n k i t i s j u s t f o r our own s e l v e s .  P. The p a t i e n t would be b r a i n dead when you come on and you c o u l d you know a s k : "Do you do a n y t h i n g ? " I mean t h e y ' r e b r a i n dead, t h e y d o n ' t know what y o u ' r e d o i n g or what y o u ' r e n o t d o i n g . But t h a t would be n e g l e c t . L i k e t h a t would s t r i k e me as n e g l e c t i f I j u s t : " T h a t ' s one b r a i n dead" and j u s t s o r t o f t u r n your b a c k . . . I  ICU  N u r s e s and t h e B r a i n  Dead  Patient 57  g u e s s i t ' s l i k e I'm f e e l i n g t h a t t h i s i s j u s t a c o n t a i n e r t h a t I am l o o k i n g . a f t e r now and I d o n ' t know there i s j u s t a b i t of c o n f l i c t there. I know t h a t i t i s t h a t t h e r e i s no one l i k e t h e r e now and y e t t o j u s t be l i k e . . . i t w o u l d n ' t b o t h e r me a b i t l i k e I s a y t o comb t h e i r h a i r even though I know t h e y ' r e g o i n g t o go i n a h a l f an hour t o be an o r g a n d o n o r . L i k e I would s t i l l want t o do t h o s e t h i n g s . And t o n o t I d o n ' t know how t o . Many o f t h e i n f o r m a n t s appropriate patient. is  and i n a p p r o p r i a t e  to a simple  w i t h what  nursing  F o r some t h e p e r s o n a l  related  cannot  struggle  care  dissonance  constitutes  of the b r a i n they  dead  experience  a c t s u c h as t a l k i n g t o a p a t i e n t  who  hear.  P. And I a l s o d o n ' t know how t o t r e a t t h e p e r s o n . . . t h e donor o r t h e p o t e n t i a l donor o r t h e b r a i n dead p e r s o n . L i k e you know i f i t ' s J e f f o r w h a t e v e r you s a y : " W e l l J e f f I'm g o i n g t o s u c t i o n y o u " . . . l i k e you would f o r any other unconscious person. But t h e n o r I w i l l j u s t t a l k to them b u t i f t h e f a m i l y i s t h e r e I do n o t know whether t o t a l k t o them o r n o t b e c a u s e your s a y i n g : " W e l l t h e y ' r e gone. They're dead. T h e r e ' s no hope. There's nothing." But t h e n you s t a r t t a l k i n g t o t h e patient! I mean t h a t i t i s s o . . . i t i s . . . I d o n ' t know i f d o u b l e s t a n d a r d i s t h e r i g h t word b u t i t g i v e s c o n f l i c t i n g i d e a s to the f a m i l y .  P. W e l l l i k e t h e l a s t c o u p l e t h a t I have had I f o u n d i t awkward when I was t a l k i n g t o t h e p a t i e n t s b e c a u s e i n my mind t h e p a t i e n t s w e r e n ' t t h e r e anymore b u t . . . I t a l k to my p a t i e n t s anyways. And I can remember when I came on t h a t n i g h t and I was t a l k i n g t o him and I f i n a l l y stopped. And why d i d I s t o p I must have f e l t . . . s o m e t h i n g made me s t o p t a l k i n g t o him... Another her  personal  p a r t i c i p a n t t a l k s to the b r a i n dissonance  centers  patient  i s dead and t h e b e l i e f  be  to hear.  able  around that  dead  p a t i e n t but  t h e knowledge t h e  the p a t i e n t  still  might  ICU  N u r s e s and t h e B r a i n Dead  Patient 58  P. I t a l k t o them as t h o u g h t h e y c a n h e a r me. They c a n ' t t h e y say. but who knows...I t e l l them who I am and what's g o i n g on. Maybe i t ' s j u s t i n c a s e I...maybe b e c a u s e I don't r e a l l y know i f they c a n h e a r o r n o t . This concept death the  clash  of b r a i n  will  and  of b r a i n  will  death  undergo  surgical problem  room he w i l l  However, n e i t h e r o f t h e s e brain  dead  evidenced this is  and p e r s o n a l  patient  viewed  i s sent  by t h e f o l l o w i n g  action  of sending  as b e i n g  about  addressing  dissonance. when she p r e p a r e s  t o t h e o p e r a t i n g room a r e t h a t t h e  h e a l t h care  recovery  of the  i n the s e c t i o n  normal e x p e c t a t i o n s of a nurse  underlying the  acceptance  dead and h e r own p e r s o n a l b e l i e f  sends a p a t i e n t  patient  the nurse's  be d i s c u s s e d f u r t h e r  concept The  between  intervention  for his  and f o l l o w i n g  a brief  r e t u r n to h i s n u r s i n g  unit.  expectations are v a l i d to the s u r g i c a l transcripts  a dead  incongruous  patient with  when a  suites.  o f two  stay i n  As  participants,  t o t h e o p e r a t i n g room  nursing care.  P. B e c a u s e you g e t v e r y s t r a n g e f e e l i n g s when you l o o k a f t e r a b r a i n dead p e r s o n and t h e n you a r e s e n d i n g them o f f t o t h e OR and t h e y ' r e warm, t h e y ' v e g o t a b l o o d p r e s s u r e and a h e a r t r a t e b u t you know THAT t h e y a r e not g o i n g t o be coming back  P. To be l o o k i n g a f t e r a f a m i l y member t h a t ' s DEAD and you've t o l d them t h a t maybe i t ' s j u s t a s t r a n g e t h i n g to be p r o v i d i n g c a r e t o someone who you know i s g o i n g to t a k e h i s p a r t s away and I g u e s s I c a n ' t d i s t a n c e m y s e l f enough from t h a t t o f e e l c o m f o r t a b l e d o i n g . . . i t ' s p r o b a b l y s o m e t h i n g I ' d r a t h e r n o t do b u t i t ' s t e c h n i c a l l y and p h y s i c a l l y n o t a more d i f f i c u l t p a t i e n t to look a f t e r . . . I t ' s p h y s i c a l l y e a s i e r . I t ' s e m o t i o n a l l y more d i f f i c u l t . . . I keep s t a r i n g a t t h i s bed and t r y i n g t o v i s u a l i z e a s i t u a t i o n um I t h i n k i t ' s  ICU  Nurses  and t h e B r a i n  Dead  Patient  59  because I don't r e a l l y think of i t as nursing. Ah maybe t h a t ' s p a r t o f i t . T h e r e i s s o m e t h i n g t h a t ' s a b i t um k i n d o f u n n a t u r a l a b o u t i t i n a way. A n d maybe b e c a u s e I would r a t h e r t h a t they were dead l i k e I would r a t h e r l i k e t o be l o o k i n g a f t e r a p a t i e n t b e f o r e t h e b r a i n dead p a r t . I t ' s e v e n ok i f t h e y ' r e b r a i n d e a d b u t i t ' s t h e s h i f t , t h e s h i f t I come o n a n d y o u ' r e w a i t i n g f o r t h e OR a n d y o u c o u l d be w a i t i n g 8 h o u r s .  P. T h e f i r s t t i m e i t was w e i r d . I t h o u g h t i t was k i n d o f a g r o s s t h i n g c a u s e y o u s e n d a c r o s s a warm p e r s o n and n o t h i n g comes b a c k e x c e p t an empty b e d . And t h a t i s not a normal nursing thing. The n o r m a l nursing t h i n g i s y o u s e n d s o m e b o d y t o t h e OR a n d y o u g e t somebody b a c k . I t j u s t s o r t o f goes w i t h i t , r i g h t ? B u t y o u s e n d a p a t i e n t t o t h e OR f o r PORT t h a t ' s i t , s o t h e f i r s t t i m e i t was r e a l l y w e i r d b e c a u s e I d o n ' t r e a l l y t h i n k I h a d t h o u g h t a b o u t w h a t I was a c t u a l l y doing. I was j u s t I mean i t ' s y o u r f i r s t t i m e a n d y o u j u s t do t h i s t h i n g . You j u s t f o l l o w i t and t h e n a l l o f a s u d d e n o u t t h e d o o r he went a n d t h e d o o r c l o s e d a n d I thought: " T h i s person i s n ' t coming back." Even retrieval to  i f the p a r t i c i p a n t and t r a n s p l a n t a t i o n  the operating  instance,  the  t o do f o r t h e b r a i n  there  room.  strong  sending  i s associated  f o r harvesting  operating  suite  room  o n e p a r t i c i p a n t who  obligation thing  i s a  By  organs" dead  sending  i s no c l o s u r e  a brain  with  believes also  patient  advocate dead  finds  "we  i s to send  the patient  For  have  the  organ  patient  discord.  that  f o r her nursing  of  a  moral  hardest them t o  to the s u r g i c a l  care  with  that  patient. P. When t h e y a c t u a l l y t a k e o f f f o r t h e OR I h a v e t o a n d t h i s i s s o r t o f a . . . o h I d o n ' t know how I w o u l d p u t i t . . . s o r t o f an e m p t i n e s s i n t h a t r e g a r d . Probably b e c a u s e I'm n o t g o i n g t o f i n i s h t h e j o b i n t h e s e n s e t h a t I am n o t g o i n g t o be w i t h t h e p a t i e n t until they're dead. Y o u know f i n i s h t h e j o b . T h a t s o u n d s t e r r i b l e d o e s n ' t i t ? B u t I mean I ' v e d o n e a l l I c o u l d do when I e x a m i n e t h e n u r s i n g s o a n d I'm n o t g o i n g t o  ICU  N u r s e s and t h e B r a i n Dead P a t i e n t  60 f i n i s h o f f . L i k e w i t h a b r a i n dead p a t i e n t u s u a l l y y o u ' r e g o i n g t h r o u g h t h e v a r i o u s s t e p s and y o u ' r e n o t g o i n g t o t a k e t h e o r g a n s . . T h e y ' r e j u s t g o i n g t o be t u r n e d o f f and so t h e r e ' s v a r i o u s s t e p s t h a t you t a k e w i t h them i n mind. L i k e you go o u t and t a l k t o t h e f a m i l y and t h e y ' v e been spoken t o . They come i n and say t h e i r good-byes and you s o r t o f t a l k t o them and h e l p them o u t . And e x p l a i n t h a t t h e machine i s t h e r e i s between him and d e a t h . And s i t w i t h t h e w i f e maybe and e n c o u r a g e them t o h o l d h i s hand and so on. And t h e n t h e machine i s t u r n e d o f f . O f t e n what happens t h e y go away sometimes f o r a h a l f an hour o r so and you can s i t w i t h them and w a i t and p e r h a p s t a l k . And t h e n you've gone t h r o u g h t h e whole p r o c e s s w i t h them i n a sense i t ' s l i k e the g r i e v i n g p r o c e s s y o u r s e l f . You're doing a l l the s t e p s w i t h the f a m i l y . And t h e n I f i n i s h off. I wash t h e body and I p u t i t i n a bag and I c a l l the p o r t e r and we go down t o t h e morgue. So i n a s e n s e I've gone t h e whole s t e p y e a h . Whereas I t h i n k when I've g o t them g o i n g t o t h e OR I h a v e n ' t really. This  participant,  ventilator  f o r t h e p a t i e n t when t h e  was d i s c o n t i n u e d and by c a r i n g  afterwards, others  by c a r i n g  i s able  though  inconsistent  to a c h i e v e  a sense  f o r t h e body  of consonance.  For  the d i s c o n t i n u a t i o n of the v e n t i l a t o r i s with  nursing  care.  P. But t h e r e i s j u s t s o m e t h i n g t h a t i s i n c o n g r u e n t a b o u t b e i n g a n u r s e and t u r n i n g a v e n t i l a t o r o f f , I think. R. And how do you f e e l  at that  time?  P. Q u i t e s t r a n g e . I t almost... f e e l s a b i t unreal b e c a u s e i t i s so c o n t r a r y t o what we do. The  a c t i o n s of sending  a dead  p a t i e n t to the o p e r a t i n g  room and d i s c o n t i n u i n g t h e v e n t i l a t o r the  participants  as b e i n g  components o f t h e i r This  results  behaviours.  roles  though a c k n o w l e d g e d by  abnormal a c t i v i t i e s as i n t e n s i v e  f o r nurses are  care unit  nurses.  i n c o g n i t i o n s which a r e i n o p p o s i t i o n to For others  the f l u r r y  of n u r s i n g  activity  ICU  N u r s e s and  t h e B r a i n Dead P a t i e n t 61  around the p a t i e n t ' s bedside concept  of  i s inconsistent with  the  death.  P. And y o u ' r e s a y i n g t h e y ' r e gone and y o u ' r e r u n n i n g a r o u n d l i k e mad t r y i n g t o keep t h e b l o o d p r e s s u r e , and t h e u r i n e o u t you know t h e i r volume up, t h e y ' r e p e e i n g o u t and I have t r o u b l e r e l a t i n g t h e two. Or I t h i n k t h e f a m i l y has t r o u b l e r e l a t i n g t h e two. L i k e you're s a y i n g t h e y ' r e gone and t h e n y o u ' r e r u n n i n g a r o u n d t r y i n g t o keep t h e body g o i n g . W h i c h you a r e .  P. The o n l y t h i n g i s t h a t when l o o k i n g a f t e r an o r g a n d o n o r b r a i n dead p a t i e n t I t h i n k i t must be h a r d f o r the f a m i l y because you're r u n n i n g around... doing a l l t h e s e t h i n g s t h a t you d o n ' t do t o a b r a i n dead p a t i e n t t h a t ' s j u s t l a y i n g t h e r e and i s g o i n g t o go d i e whenever. You know when i t ' s a d o n o r . . . o r g a n d o n o r you're doing e x t r a s you're doing echos, you're doing b l o o d t e s t , y o u ' r e d o i n g t h i s and y o u ' r e d o i n g t h a t . You know i f t h e i r e l e c t r o l y t e s , y o u ' r e c h a s i n g t h e p o t a s s i u m o r t h e s u g a r s o r t h e y ' r e i n DI and y o u ' r e d o i n g t h i s and d o i n g t h a t you know so you j u s t have t o keep m a k i n g s u r e t h a t t h e f a m i l y u n d e r s t a n d t h a t t h a t a l o t o f t i m e s y o u ' r e r e a l l y busy t h e r e i s s o m e t i m e s two n u r s e s r u n n i n g a r o u n d d o i n g t h i n g s and a l l t h a t . So you j u s t have t o t h i n k o f t h e f a m i l y and you have t o say t o them t h a t y o u ' r e d o i n g t h i s b e c a u s e you want t o p r e s e r v e t h e i r o r g a n s so someone e l s e can use them b u t r e a l l y i f we w e r e n ' t d o i n g a n y t h i n g t h e n t h e p a t i e n t p r o b a b l y w o u l d t h e p a t i e n t w o u l d d i e b e c a u s e we're k e e p i n g them a l i v e f o r a r e a s o n . Finally, desire  t o do  d i s c o r d may something  but  r e s u l t when t h e n u r s e  situation  i s e v i d e n t i n one  This  at the  to  internal  participant's description  i n v o l v i n g a young b r a i n dead m o t h e r whose  c h i l d r e n were p r e s e n t  the  i s u n c e r t a i n o f what t o do due  l a c k of e x p e r i e n c e , i n f o r m a t i o n or s u p p o r t . dissonance  has  of a  two  bedside.  P. But t h i s l i t t l e n i n e y e a r o l d g i r l w i t h l o n g c u r l y b l a c k h a i r and huge brown e y e s , e y e s l a s h e s t h a t were an i n c h l o n g who went i n t o t h e room and t h r e w h e r s e l f on t h e bed and s a i d : "Mommy wake up. I need y o u . I  ICU  N u r s e s and  the B r a i n Dead P a t i e n t 62  l o v e y o u . " and t h e n f l u n g h e r s e l f a t me. H u g g i n g me s a y i n g : " I d o n ' t u n d e r s t a n d why t h i s i s h a p p e n i n g . " And I s a t down and she s a t on my l a p and hugged. It was j u s t the most e m o t i o n a l e x p e r i e n c e I have e v e r e n c o u n t e r e d i n my n u r s i n g c a r e e r and i t was h o r r i b l e . I d i d n ' t know what t o do w i t h t h i s g i r l . I thought t h a t i t was a v e r y d e l i c a t e s i t u a t i o n t h a t I wanted t o h a n d l e a p p r o p r i a t e l y f o r f e a r of r u i n i n g her f o r the r e s t of her l i f e . I t r i e d t o phone any r e s o u r c e s t h a t I c o u l d and f e l t l i k e I wasn't g e t t i n g the s u p p o r t t h a t I wanted. Ah [ t h e c h a p l a i n ] had a c o l d w h i c h i s f i n e . And her r e p l a c e m e n t wasn't r e a l l y s u r e what we s h o u l d be d o i n g . I c o u l d n ' t g e t any a n s w e r s as t o what the a p p r o p r i a t e , i f anyone had any s u g g e s t i o n s on how t o d e a l w i t h a k i d b e c a u s e I had n e v e r d e a l t w i t h a c h i l d before. The D i r e c t o r of the u n i t was u n u s u a l l y i n s e n s i t i v e t h a t day, w h i c h I f o u n d v e r y a n n o y i n g . . . And i t was v e r y t o u g h . Very tough. And i t ' s s t i l l on my mind . The  disharmony  this  around  her  knowledge  result  in irreversible  participant  t h a t her  feels  d e s i r e t o do  harm t o the  also  centers  something  may  daughter.  P. I was a f r a i d of was making comments t h a t would put t h e k i d o f f c o m p l e t e l y from e v e r g o i n g to the h o s p i t a l or w a n t i n g t o go t o the d o c t o r or h e a r i n g the e x p r e s s i o n : " W e l l dad i s n ' t f e e l i n g w e l l he i s g o i n g t o the d o c t o r . " Or someone s a y i n g t o h e r : " W e l l gee I have a h e a d a c h e " and t h e n she i s g o i n g to t h i n k t h a t t h a t p e r s o n i s g o i n g t o be b r a i n dead. Like I think II took i t t o t h a t e x t e n t t h a t I was a f r a i d t h a t I was g o i n g t o do some s o r t of o f i r r e v e r s i b l e damage to her p s y c h e by making the wrong comment...it was a d e l i c a t e s i t u a t i o n t h a t had t o be h a n d l e d p r o p e r l y and I d i d n ' t f e e l l i k e I was c a p a b l e of h a n d l i n g i t p r o p e r l y . Concept The concept is  clear  of b r a i n  death.  participants of b r a i n  indicate  death.  that at l e a s t  difficulty  accepting  signs without  a general acceptance  However, from two  the  additional  of  the  the  physical  proof.  the  transcripts, i t  participants  d i a g n o s i s based  of  have  o n l y on  clinical  This creates a  ICU  N u r s e s and t h e B r a i n Dead  Patient 63  dissonant the  situation  where t h e n u r s e ' s p e r s o n a l  p a t i e n t opposes her knowledge t h a t  declared  belief  about  t h e p a t i e n t h a s been  dead.  P. And j u s t b e c a u s e t h a t p a t i e n t h a s been d e c l a r e d b r a i n d e a d , t h e y ' r e s t i l l l y i n g on a bed and t h e y ' r e s t i l l b r e a t h i n g on a v e n t i l a t o r and s t u f f . I t doesn't mean t h a t he i s DEAD a s f a r a s I'm c o n c e r n e d o r a s f a r as t h e f a m i l y i s p r o b a b l y c o n c e r n e d . R. So p e r s o n a l l y b r a i n death?  how do you f e e l a b o u t t h e c o n c e p t o f  P. I t h i n k s o m e t i m e s when y o u s e e t h e EEG and s e e a l l t h e f l a t l i n e s and s t u f f THAT i s more s i g n i f i c a n t t h e n s e e i n g . . . t h e n n o t s e e i n g a n y t h i n g and somebody t e l l i n g you he i s b r a i n d e a d . A l l t h e c a l o r i c s and a l l t h e d i f f e r e n t r e f l e x e s they check f o r . R. So you need s o m e t h i n g b e s i d e s t h e u s u a l c r i t e r i a o f b r a i n death? You need some s o r t o f p r o o f t h a t t h e y a r e b r a i n dead t h e n ? P. I t h i n k t h a t way. whatever.  i t makes i t e a s i e r t o d e a l w i t h t h e p a t i e n t I f t h e r e i s some c o n c r e t e d r a w i n g s o r  P. B u t I a l w a y s l i k e t o r e a d i f t h e y had a CT S c a n , what t h e s c a n show and why...what shows t h a t t h e p e r s o n i s b r a i n dead...The ones t h a t you know w e l l g e e z I g u e s s t h e y ' r e SURE b u t I g u e s s t h e r e ' s a l w a y s t h a t d o u b t t h a t you know I g u e s s l i k e t h e f a m i l y t o o you know t h e y a l w a y s c a n t h i n k w e l l you know I hope t h e y ' r e s u r e o r you know t h a t you know b u t I mean w i t h us s o m e t i m e s you c a n j u s t s e e t h a t p h y s i c a l t h a t t h e y ' r e n o t bad b u t t h e y cone [ h e r n i a t e ] r i g h t t h e r e w e l l t h e n you know f o r s u r e . B u t s o m e t i m e s y o u d o n ' t have t h e s e physical signs. They j u s t l o o k so p e a c e f u l and t h e y ' r e j u s t l y i n g t h e r e and you t h i n k : "God how c a n t h e y be b r a i n dead when t h e y l o o k so good o r w h a t e v e r . . . " I t ' s h a r d on me t o t h i n k w e l l you know I g u e s s t h e y a r e b r a i n dead b u t . . . The be  dissonance t h i s p a r t i c i p a n t describes  due t o t h e v i s u a l  s t i m u l i regarding  may i n p a r t  the p a t i e n t ' s  ICU  N u r s e s and t h e B r a i n Dead P a t i e n t 64  clinical the  appearance c l a s h i n g with  appearance of death.  participants  illustrate  the nurses'  beliefs  The f o l l o w i n g a c c o u n t s this  about  of s i x  point.  P. When you s e e t h e h e a r t b e a t and t h e c h e s t r i s e and f a l l and t h e r e s p i r a t i o n r a t e w i t h t h e r e s p i r a t o r , b l o o d p r e s s u r e and s t u f f t h e n I s o r t o f f e e l t h a t t h e r e i s something t h e r e .  P. I t ' s h a r d e r b e c a u s e you a r e t r y i n g t o c o n v i n c e t h e f a m i l y t h a t t h e y a r e b r a i n dead and you a r e l o o k i n g a t them and y o u ' r e l o o k i n g a f t e r them and sometimes i t i s h a r d t o remember t h a t t h e p a t i e n t c a n l o o k t o t a l l y n o r m a l and be b r a i n dead and you a r e t a l k i n g t o them w h i l e you a r e d o i n g t h e b l o o d work b e c a u s e we u s u a l l y t a l k t o our p a t i e n t s anyways and sometimes you w i l l c a t c h y o u r s e l f and you w i l l have t o keep t e l l i n g y o u r s e l f t h a t you know r e m i n d i n g y o u r s e l f t h a t t h i s p e r s o n i s b r a i n dead. I t h i n k i t i s h a r d e r when t h e y look normal. When t h e y ' r e n o t a l l bashed up.  P. I g u e s s my f i r s t f e e l i n g I g u e s s i s t h a t you r e a l l y wonder w e l l I wonder i f he r e a l l y i s b r a i n dead l i k e I mean b e c a u s e you know and I'm s u r e t h a t ' s what t h e f a m i l i e s go t h r o u g h . You l o o k a t them and a l o t o f them d o n ' t l o o k l i k e t h e y even you know t h e y ' r e n o t l i k e you know l i k e w i t h b l o o d a l l o v e r or i n c i s i o n s a l l o v e r you know u n l e s s t h e y ' v e been l i k e a l l t h e o t h e r o r g a n s a r e bad o r w h a t e v e r . A l o t o f them t h e y d o n ' t seem t h a t bad you know. Like i f they're a subarachnoid bleed or whatever t h e y ' r e p e r f e c t l y h e a l t h y otherwise except f o r t h e i r b r a i n .  P. And she l o o k e d so p e r f e c t , t h e mom, you know. I mean she l o o k e d so p e r f e c t as t h e y u s u a l l y do you know. And h e r h a i r was n i c e and combed and and she l o o k e d l i k e she was a s l e e p w i t h - a tube i n h e r mouth.  P. I g u e s s one m i n u t e t h e y ' r e a l i v e and t h e next t h e y ' r e dead. But a l s o t h e y d o n ' t n e c e s s a r y l o o k  dead.  ICU  Nurses.and  the B r a i n  Dead  Patient  65 You know some o f them do n o t have a mark on them. have a l l t h e s e t u b e s i n them. For youth  some t h e c o m b i n a t i o n  seems i n c o n s i s t e n t  with  o f a normal  appearance  We  and  death.  P. Yeah i t ' s n o t f u n c t i o n i n g we're d o i n g a l l t h e work f o r i t . But sometimes l i k e t h e l a s t one I had i t was r e a l l y d i f f i c u l t b e c a u s e he was o n l y s i x t e e n and i t j u s t r e m i n d e d me b e c a u s e I have a son o f my own and i t was a young man and t h a t made i t r e a l l y d i f f i c u l t and i t was l i k e he was s t i l l a l i v e . R. The p a t i e n t  was s t i l l  alive?  P. Yeah t h e p a t i e n t was s t i l l a l i v e ( v o i c e v e r y s o f t ) and i t was j u s t ah b e c a u s e t h e r e was n o t h i n g t h a t wasn't i n t a c t l i k e h i s s k i n was s t i l l on. He s t i l l l o o k e d l i k e a human b e i n g and i t was j u s t r e a l l y s c a r y to s e e t h a t . A body t h e r e b e i n g m a i n t a i n e d j u s t so i t can be r e t r i e v e d . . . f o r d o n a t i o n and s t u f f l i k e .  P. And s e e i n g t h i s young f a c e l y i n g on t h i s bed and they g e n e r a l l y l o o k p e r f e c t l y f i n e e x c e p t t h a t t h e y have t h i s i r r e p a r a b l e head i n j u r y and t h e y don't have any l i m b s b r o k e n o r a n y t h i n g . I t ' s hard t o . t h i n k that t h i s p e r s o n i s a c t u a l l y b r a i n dead, a t f i r s t . And I f i n d i t e a s i e r now j u s t b e c a u s e o f t h e e x p e r i e n c e t h a t I have had w i t h i t . One p a r t i c i p a n t patient  also  states  t h e r e i s a need  to see the  as dead.  P. I t h i n k i n anybody when y o u ' r e d e a l i n g w i t h d e a t h i t i s so much e a s i e r a c t u a l l y t o s e e t h e p e r s o n DEAD. See them w i t h no l i f e i n them b e f o r e you c a n a c c e p t t h a t . I t h i n k i n any s i t u a t i o n i f you h e a r about somebody t h a t d i e d i t i s h a r d t o a c c e p t t h a t u n l e s s you a c t u a l l y see them. This easy  same p a r t i c i p a n t  concept  even  indicates  f o r nurses  brain  death  i s n o t an  to grasp.  P. I t h i n k sometimes even f o r n u r s e s i t ' s h a r d t o u n d e r s t a n d t h e c o n c e p t o f b r a i n d e a t h and i t ' s sometimes i t ' s h a r d t o u n d e r s t a n d t h a t t h i s i s a b r a i n  ICU  N u r s e s and t h e B r a i n Dead P a t i e n t 66  dead p a t i e n t even f o r new n u r s e s when t h e y [ t h e b r a i n dead p a t i e n t ] cone and t h e y s e e t h i s p a t i e n t a t t a c h e d to a v e n t i l a t o r . I t ' s h a r d ,to u n d e r s t a n d t h a t t h e y a r e not j u s t i n a coma and t h a t t h e y a r e dead. For  some p a r t i c i p a n t s  diagnosis  t h e r e i s i n c o n s i s t e n c y when t h e  i s made b e c a u s e n o t h i n g  appears  t o be as he was b e f o r e  despite  this  difference  has c h a n g e d .  t h e d i a g n o s i s was made b u t  he i s now c o n s i d e r e d  i s t h e equipment  The p a t i e n t  dead.  i s now  The o n l y  obvious  gone.  P. Yeah, I t h i n k t h a t i t ' s s o m e t h i n g t h a t a l l o f t h e sudden you've made t h i s d e c i s i o n and you have been c a r i n g f o r t h i s p e r s o n who i s b r a i n dead and t h e n you s h u t e v e r y t h i n g o f f and i t ' s s t i l l t h e same p e r s o n and t h e y ' r e s t i l l b r a i n dead b u t t h e r e i s j u s t n o t h i n g going. T h e r e i s no equipment g o i n g so t h e r e f o r e t h e y ' r e dead. L i k e when t h e r e i s equipment g o i n g and you see t h e h e a r t b e a t and t h e b l o o d p r e s s u r e and you s t i l l t h i n k t h e y ' r e a l i v e even though t h e y ' r e b r a i n dead and s h u t t i n g them o f f i s j u s t s o r t o f l i k e t h e f i n a l : " T h a t ' s i t , n o t h i n g more" b u t i t ' s f r u s t r a t i n g b e c a u s e t h e r e i s no r e a l l i n e t h e r e ! Even t h o u g h you saw t h e h e a r t b e a t and t h e b l o o d p r e s s u r e and s t u f f t h e person i s s t i l l not t h e r e . I t ' s s t i l l b r a i n dead b u t i t ' s m o r e . . . i t ' s r e a l i t y when you s h u t e v e r y t h i n g o f f . You don't s e e a n y t h i n g on t h e m o n i t o r s . They d o n ' t breathe. Then you, t h e n I r e a l i z e t h a t t h a t p e r s o n i s dead. When you s e e t h e h e a r t b e a t and t h e c h e s t r i s e and f a l l and t h e r e s p i r a t o r r a t e w i t h t h e r e s p i r a t o r , b l o o d p r e s s u r e and s t u f f then I s o r t o f f e e l t h a t t h e r e i s something t h e r e . Three at  t h e time  participants of d e c l a r i n g  indicate  that dissonance  the p a t i e n t b r a i n  dead  occurs i f treatment  does n o t c e a s e . P. T h e r e i s some f r u s t r a t i o n sometime and you've s o r t of f a i l and y e t y o u ' r e s t i l l c o n t i n u i n g on. You've r e a l l y f a i l e d t o save t h e i r l i v e s and y e t y o u ' r e still c o n t i n u i n g on t o c a r e f o r them. You know i t ' s l i k e hopeless s i t u a t i o n . . . i t ' s hard to e x p l a i n .  ICU  N u r s e s and t h e B r a i n  Dead  Patient 67  P. Ah I f i n d i t r e a l l y h a r d . I f i n d up u n t i l t h e p o i n t when we're c l a s s i f i e d as b r a i n dead i s one t h i n g b u t t h e r e i s s o m e t h i n g t h a t t r i g g e r s o f f i n my mind t h e m i n u t e t h e y ' r e n o t g o i n g t o be d o n o r . I t ' s l i k e I'm done w i t h t h a t p a t i e n t . L i k e I ' v e done a l l I c a n do and now t h e y ' r e g o n e . . . I know t h e r e a r e a l o t o f t h i n g s e t h i c a l l y t h a t a r e v e r y d i f f i c u l t i n ICU and I g u e s s I just think t h e i r l i f e i s over. They s h o u l d be t a k e n off immediately. When t h e y ' r e c o n s i d e r e d b r a i n dead t h e y ' r e dead. Take them o f f and l e t them be. Their l i f e i s f i n i s h e d you know. And t h a t ' s h a r d i f t h e y ' r e not. I d o n ' t know how e l s e t o d e s c r i b e i t you k n o w . . . I d e a l l y i n my mind once a p a t i e n t i s c o n s i d e r e d b r a i n dead t h e y s h o u l d be t a k e n o f f t h e v e n t i l a t o r i f t h e y a r e n o t g o i n g t o be an o r g a n donor and t h a t ' s i t . The f a m i l y s h o u l d be t o l d t h a t they a r e dead and we're g o i n g t o t a k e them o f f t h e v e n t i l a t o r and t h a t ' s i t and t h e y ' r e t a k e n away. But sometimes i t d o e s n ' t a l w a y s happen. So I g u e s s f o r me I j u s t s o r t o f t r y and f l o w w i t h i t . And I'm n o t g o i n g t o be a b l e t o do a n y t h i n g a b o u t i t and maybe t h e r e i s a p a r t o f me t h a t k i n d o f s h u t s o f f and I w i l l do what I have t o t o t a k e c a r e o f t h a t p a t i e n t u n t i l t h e y go. But I g u e s s my h e a r t and soul i s n ' t into i t .  P. I f t h e p e r s o n i s gone and b r a i n dead and we're g o i n g f o r o r g a n d o n a t i o n t h e n I w i l l go a l l o u t b u t i f t h e y ' r e b r a i n dead and we a r e j u s t h a n g i n g a r o u n d , p a s s i n g time t h e n f o r g e t i t . J u s t s t o p i t . I s e e no point i n i t . Yet with the  f o r another  the parents  of a seventeen  discontinuation  after  the d i a g n o s i s  relates  to the f a c t  diagnosis  n u r s e when she made an " i n s t a n t  of b r a i n  year  old brain  o f t h e v e n t i l a t o r happened was made. that  Her p e r s o n a l  she r e i n f o r c e d  death which  dead  bond" patient  too q u i c k l y  dissonance  to the f a m i l y the  she p e r s o n a l l y  d i d not  accept. P. Maybe b e c a u s e you know our f a m i l y b e i n g t h e same age I s o r t of i d e n t i f i e d with that I thought I c o u l d n ' t w o u l d n ' t want t o make t h a t d e c i s i o n t h a t f a s t . Like t h a t would have been s o m e t h i n g I would have r e g r e t t e d  ICU  Nurses  and t h e B r a i n  Dead  Patient 68  f u r t h e r on a c o u p l e o f months down t h e r o a d . I mean you know t h a t a l l took p l a c e w i t h i n t w e l v e h o u r s o r w e l l from t h e time o f a d m i s s i o n i t was more t h a n t w e l v e i t was p r e t t y w e l l t w e n t y - f o u r f r o m t h e time o f admission. And you know maybe he would have opened up you know o r maybe we s h o u l d ' v e had a n o t h e r n e u r o s u r g e o n come i n and t a l k t o us o r s o m e t h i n g and I g u e s s i t was the a c t i v e p a r t t h a t I took i n r e i n f o r c i n g you know t h e m e d i c a l d e c i s i o n . . . the d e c i s i o n came a l i t t l e b i t t o o f a s t f o r ME p e r s o n a l l y and y e t I was h a v i n g t o r e i n f o r c e i t t o t h e f a m i l y b e c a u s e i t seemed, t h a t seemed t o be t h e l o g i c a l t h i n g t o do. I mean t h i s p a t i e n t was b r a i n dead why d r a g them t h r o u g h a n o t h e r two days o f i t ? . . . i t was t o o soon f o r me l i k e i f you had a s k e d me t h a t tomorrow l i k e t h e n e x t day ah t h e n I'd say "Yes...he i s b r a i n dead and t h e r e i s r e a l l y n o t h i n g you know n o t h i n g more anybody c a n do w i t h him so you know l i k e he j u s t l i k e he has t o d i e . T h i s i s h i s time t o d i e and b a s i c a l l y he has a l r e a d y d i e d . " But i t was a l i t t l e b i t t o o f a s t f o r me and y e t I was h a v i n g t o r e i n f o r c e t h e m e d i c a l d e c i s i o n s t h a t were a l r e a d y made which I would have a g r e e d w i t h I am s u r e i n a n o t h e r day b e c a u s e I - I don't have a p r o b l e m w i t h the d i a g n o s i s f o r b r a i n dead b u t and t h e f a c t . . . h i s age i n t h i s c a s e b e i n g a s e v e n t e e n and a v e r y a c t i v e an 'A' s t u d e n t and a l l t h i s b u s i n e s s . I t was a d i f f i c u l t one and as I s a y I maybe I s h o u l d n ' t have r e i n f o r c e d i t so s t r o n g l y and maybe I s h o u l d have s a i d : " W e l l why don't you w a i t a n o t h e r day I mean i f you don't f e e l t h a t s u r e about i t why don't you w a i t a n o t h e r day and o r maybe would you l i k e someone e l s e t o t o c o n f i r m what d o c t o r so and so s a i d ? " When t h e d i a g n o s i s o f b r a i n do  something  nothing  may be i n o p p o s i t i o n  death with  i s made  the d e s i r e to  t h e knowledge  that  c a n be done.  P. I t h i n k t h e f i r s t time t h a t I l o o k e d , a f t e r t h a t b r a i n dead young boy I j u s t c o u l d n ' t h e l p t h i n k i n g t h a t t h e r e must be SOMETHING t h a t we c a n do h e r e b e c a u s e he was so young t h e r e ' s s o m e t h i n g b u t r e a l l y knowing t h e r e r e a l l y wasn't. Though many o f t h e p a r t i c i p a n t s brain  d e a t h means t h e p a t i e n t  gave t h e p a t i e n t  attributes  indicate  i s dead,  that  f o r them  a number o f n u r s e s  of the l i v i n g .  The p a r t i c i p a n t s  ICU  Nurses and the B r a i n Dead P a t i e n t 69  a l s o made r e f e r e n c e  to these i n c o n s i s t e n c i e s i n t h e i r  beliefs. R. What does b r a i n death mean to you? P. I t would mean to me maybe c e s s a t i o n of v o l u n t a r y f u n c t i o n and b a s i c a l l y your body i s j u s t working on r e f l e x a c t i o n meaning c a r d i a c and hormone b a s i c a l l y I guess and that a l l other s e n s a t i o n and f u n c t i o n has terminated. Despite  this participant's belief  that sensory  ceases with b r a i n death she a l s o holds an opposing that a b r a i n dead person might f e e l  function belief  pain.  P. One good concern that I always have was i f they use an a n e s t h e t i c or not? [ i n r e f e r e n c e to organ r e t r i e v a l ] And I spoke to one of the a n e s t h e t i s t once and he t o l d me that u s u a l l y they don't but they do use pancuronium because of f r e q u e n t l y the muscles wouldn't r e l a x and that s o r t of f o r while there i t s o r t of bothered me that they didn't use any form of a n e s t h e t i c j u s t i n case they had some s o r t of s e n s a t i o n that they could feel this incision. But I think i n time i t ' s s o r t of d e a l i n g with the r e a l i t y as to e x a c t l y what b r a i n death means that I have s o r t of come to g r i p s with that . Although i f i t was one of my f a m i l y members I might ask them i f they would j u s t use a l i t t l e n i t r o u s oxide or something j u s t i n case. I-I don't know i t ' s kind of you have these s o r t of s i l l y thoughts i n your mind that ah w e l l maybe they're not s i l l y because i t ' s something t h a t ' s on your mind. In a d d i t i o n , s e v e r a l of the p a r t i c i p a n t s i n d i c a t e that they b e l i e v e the p a t i e n t i s dead but they a l s o provide and want to provide  nursing  care which w i l l make the p a t i e n t  comfortable. R. Can you t e l l to you?  me what b r a i n death or b r a i n dead means  P. Ok w e l l going by the t e s t i n g s that we d o . . . l i k e the i c e water i r r i g a t i o n s and the f l a t EEGs and the apneic t e s t to me...they are not able to support l i f e without the r e s p i r a t o r p r i m a r i l y . . . I want to do things f o r them  ICU  Nurses  and t h e B r a i n  Dead  Patient 70  t h a t I p e r c e i v e w i l l be c o m f o r t i n g f o r them even though I'm aware t h a t t h e y a r e n o t a b l e t o f e e l i t b u t and a n y t h i n g t h a t c a u s e s them p a i n I w o u l d n ' t do.  P. W e l l t o me b r a i n dead i s t h e p e r s o n t h e b r a i n i s DEAD. They might have t h e h e a r t g o i n g or t h e y m i g h t . . . w e l l u s u a l l y t h e y a r e on a v e n t i l a t o r and t h i s but t o me l i k e t h e s o u l o r t h e b r a i n i s GONE and t h a t p e r s o n t h e way t h e p e r s o n was when a l i v e w i l l n e v e r be the same. L i k e t h e p e r s o n i s gone. I t ' s just that m e c h a n i c a l t h i n g s a r e s t i l l f u n c t i o n i n g but l i k e the b r a i n that c o n t r o l s e v e r y t h i n g i s not...but I j u s t t h i n k w e l l I made t h a t p e r s o n ' s l a s t few h o u r s i n t h i s w o r l d more c o m f o r t a b l e o r w h a t e v e r and i f t h e y c a n be i f t h e r e was any c h a n c e t h a t you know b r a i n dead p e o p l e s t i l l c o u l d see o r t h e y c o u l d f e e l o r t h e y c o u l d w h a t e v e r t h e n t h e y know t h a t i t wasn't a t r a u m a t i c ending... Participants concept  of b r a i n  concept  of death.  also death  indicate  that  though  i t was n o t c o n s i s t e n t  they a c c e p t the with  their  P. I f t h e p e r s o n i s a c t u a l l y dead t h e n t h a t ' s . . . w e l l now I'm g e t t i n g h e r e two t h i n g s . Cause I b e l i e v e t h e p e r s o n i s a c t u a l l y gone, d e a d . But t h e body i s s t i l l a l i v e ! . . . J u s t you know i f t h e y took away t h e v e n t i l a t o r and t h a t t h e p e r s o n would n o t b r e a t h e . They a r e v i r t u a l l y dead b e c a u s e d i f f e r e n t p a r t s o f t h e body c a n l a s t d i f f e r e n t l e n g t h s o f t i m e . . . N o t a n y t h i n g t h a t took a l o n g time t o work t h r o u g h b u t i t [ t h e b r a i n dead p a t i e n t ] was s o m e t h i n g t h a t I had n e v e r seen b e f o r e . You r e a d and t h e n when you s e e . I t ' s j u s t d i f f e r e n t you know b e c a u s e t h e p e r s o n t h e body i s a l i v e b u t t h e r e ' s n o t h i n g l e f t u p s t a i r s and i t j u s t t a k e s a l i t t l e b i t of adjustment...  P. I s e e them a s two d i f f e r e n t d e a t h s . B r a i n death meaning no l o n g e r v i a b l e . T h a t he i s no l o n g e r v i a b l e but d e a t h i s t h e time t h e b r e a t h i n g s t o p s and t h e h e a r t stops. T h a t i s t h e a c t u a l DEATH. I mean I don't know as I s a y I have n e v e r t h o u g h t o f t h e c o n c e p t o f b e i n g dead and b e i n g DEAD. B r a i n dead and p h y s i c a l l y d e a d . . . B r a i n d e a t h i s t h e d e a t h o f an o r g a n t h a t i s t h e o r g a n t h a t k e e p s you a l i v e . So t h a t i s t o me b r a i n  ICU  N u r s e s and  the  Brain  Dead  Patient  71 DEATH. So when you you c a n ' t l i v e i f y o u ' r e b r a i n dead obviously. You c a n ' t . . . e s s e n t i a l l y m i n d l e s s . Ok t h a t ' s the s o u l but d e a t h i t s e l f i s when the machine i s t u r n e d o f f and the h e a r t stops...When t h e r e ' s a c o m p l e t e body d e a t h . Organ r e t r i e v a l When p r o v i d i n g  and  transplantation.  care  the  care  care w i l l  r e s u l t i n organs being  the  another.  concept  dissonance  of  The  of  the  care  save  unit  the  life  patient.  When e f f o r t s to  nurse  to  focus  of  emphasis in  the  struggle  on  saving  third  saving of  not  she  her  patient supports  personal  These reasons  will  i n t e r p r e t a t i o n of  the  saving  following  of  life  three  a severely  the  the  dead  i t i s then  the  the  of  life  discord  in a  injured  nurse  patient's  patient's  The  involved  brain  save  party.  the  often  closely links  becomes b r a i n  focus  unidentified  or  that  from her  experience  reasons.  nurses are  This  patient  may  the  possibility  harvested  following  patient.  the  the  patient  accounts.  Intensive to  with  dead  n u r s e , whether  for a variety  participant's  face  transplantation,  become a p p a r e n t  struggle  n u r s e must  brain  intensive  to b e n e f i t  unit  to  to  life  the fail  difficult  organs between  for  an  the  unknown p e r s o n  the  an  a known i n d i v i d u a l and of  for  and  is  initial the  later  evident  accounts.  P. We're d o i n g i t f o r a team of d o c t o r s somewhere and y o u ' r e d o i n g i t f o r a p a t i e n t who i s w a i t i n g f o r s o m e t h i n g and you d o n ' t know t h a t p e r s o n . So y o u ' r e s o r t of I g u e s s I c a n ' t be c l i n i c a l enough to say " W e l l gee I'm d o i n g a good j o b h e r e b e c a u s e I'm g e t t i n g Joe h i s h e a r t and I'm g e t t i n g - so and so h i s k i d n e y s . "  ICU  Nurses  and  the B r a i n  Dead  Patient 72  B e c a u s e t h a t i s not what my f o c u s has been I'm n u r s e to p r o c u r e o r g a n s f o r o t h e r p e o p l e . R. So can there?  you  P.  Um  d o i n g my  R.  That's  I'm  justify  to y o u r s e l f  your  reason  not  a  f o r being  job.  what i t comes down, to?  P. W e l l I don't g e t a g r e a t s e n s e o f s a t i s f a c t i o n o v e r saving these organs. I don't. And I'm s u r e t h a t ' s why t h e r e a r e p e o p l e who work on the o t h e r s i d e o f the f e n c e t h a t get a g r e a t s a t i s f a c t i o n by t a k i n g t h o s e organs. I c a n ' t g e t e x c i t e d about i t b e c a u s e t h a t ' s not why I was l o o k i n g a f t e r t h a t p a t i e n t i n t h e beginning. I mean you c a n ' t ! I d o n ' t t h i n k you can l o o k a f t e r someone and t r y and keep them a l i v e . They go t h r o u g h and t h e y become b r a i n d e a d . I don't t h i n k you can g e t e x c i t e d about t a k i n g t h e i r o r g a n s t h e n .  P. Ok so as I was s a y i n g w i t h i n t h i s one hour p e r i o d you have a p a t i e n t t h a t you a r e g o i n g one hundred p e r c e n t b a s i c a l l y t o keep a l i v e not f o r even the i d e a f o r d o n a t i o n i n y o u r mind. And t h e y become v e r y unstable. L e t ' s say t h e y show s i g n s of c o n i n g [ h e r n i a t i n g ] or s o m e t h i n g and t h e y d e c i d e : "Ok t h i s guy's g o i n g t o cone but he i s a c a n d i d a t e f o r donation." And you a l m o s t s t a r t you gear your whole c a r e i n s t e a d o f t r y i n g t o keep t h i s p a t i e n t a l i v e f o r the p a t i e n t and t h e f a m i l y , y o u ' r e t r y i n g t o keep t h i s p a t i e n t a l i v e so t h a t t h e y a r e a s u i t a b l e d o n o r . And i t ' s i t ' s l i k e ah a l i t t l e e m o t i o n a l l y t r y i n g because y o u ' r e i n t e n s e l y l o o k i n g a f t e r t h i s m a n . . . l e t ' s say as an example and t h e n the whole f o c u s g e t s o n t o t h e i r k i d n e y s , o r t h e i r h e a r t and l u n g . And i t ' s l i k e the whole p e r s o n , t h e p e r s p e c t i v e of the whole p e r s o n i s t a k e n away and t h e n you a r e ORGAN NURSING t o a c e r t a i n e x t e n t i f t h a t makes any s e n s e . And t h a t ' s sometimes a l i t t l e hard to d e a l w i t h . Now g e n e r a l l y i t ' s o v e r a l o n g e r p e r i o d o f time l e t ' s say or i t ' s an e x p e c t e d thing. We're g e t t i n g a trauma from up n o r t h and t h e y a r e b r a i n dead or t h i s p e r s o n i s coming i n and t h e y a r e b r a i n dead um o r s u i c i d e . You know g e n e r a l l y t h e r e i s a l i t t l e more w a r n i n g . But t h e r e has been t i m e s where i t h a s n ' t even been a c o n s i d e r a t i o n b e c a u s e they a r e a trauma t h a t i s l o o k i n g l i k e t h e y a r e g o i n g t o do ok and t h e n f o r some r e a s o n or a n o t h e r t h e y d o n ' t . And t h a t ' s  ICU  Nurses  and t h e B r a i n  Dead  Patient 73  a l i t t l e b i t d i f f i c u l t g e t t i n g i n t o t h a t b e c a u s e you have t o s o r t o f c o m p l e t e l y s w i t c h your g e a r s .  P. We s e e t h e p e r s o n come t h r o u g h t h e d o o r . We s e e t h e family. You g e t s o r t o f knowing about t h e h i s t o r y o f the person, r i g h t ? T h a t ' s a l l we s e e . And t h e n we see the p a t i e n t go t o t h e OR, r i g h t ? So we a r e t i e d up I guess i n t h e f e e l i n g s o f t h e f a m i l y ' s g r i e f c a u s e I'm s u r e t h a t washes o v e r us you know. I mean no m a t t e r what we say o r what we do I'm s u r e t h a t a f f e c t s us you know. We l e a r n t o throw i t o f f b u t I'm s u r e t h a t a f f e c t s us t h e way we l o o k a t t h i n g s . But t h e PORT p e o p l e t h e y must g e t t o s e e t h a t Mrs J o n e s g o t t h i s k i d n e y : . "Look how w e l l she i s d o i n g now." So t h a t must be t h e i r b e n e f i t b e c a u s e t h e y [PORT] c a n ' t g e t i t coming i n h e r e , you know. They a l s o d o n ' t know a n y t h i n g about what's gone on b e f o r e . They come i n . They p i c k up t h i s p a t i e n t and away t h e y go. Some p a r t i c i p a n t s transplantation encountered family  of  caring  belief  i n caring  their  they  f o r the b r a i n  i f they belief  f o r an o r g a n  that  t h e end r e s u l t o f  b u t due t o t h e d i f f i c u l t i e s  a r e unsure  Therefore,  support  themselves  dead  patient  could  i n transplantation donor  themselves  they  and h i s  be d o n o r s . and t h e i r  i s inconsistent could  have  with  n o t be o r g a n  action  their  donors.  P. I t has made me t h i n k more about o r g a n d o n a t i o n . When I f i r s t came h e r e I was v e r y gung-ho about b e i n g an o r g a n d o n o r . I t h i n k I have seen so many d i f f e r e n t s i t u a t i o n s t h a t a t t i m e s t h i s i s f o r m y s e l f t h a t I have t h o u g h t "Boy I d o n ' t r e a l l y know i f I want t o go through with t h i s . I d o n ' t r e a l l y know i f I want t o put my f a m i l y t h r o u g h t h i s . " T h e r e seems t o be so many l i t t l e c o m p l i c a t i o n s t h a t sometimes I ' v e t h o u g h t "Do I r e a l l y want t o f i l l o u t t h i s c a r d t o be an o r g a n donor?" I know i t ' s v e r y s e l f i s h o f me t o t h i n k t h a t but I guess I have j u s t seen s i t u a t i o n s o f t h e f a m i l y has t o t h r o u g h so much and i t seems t o be so t e d i o u s sometimes t h a t you sometimes wonder i f i t ' s w o r t h i t . I mean I know i t ' s w o r t h i t i n t h e l o n g r u n i f i t ' s g o i n g t o h e l p someone e l s e b u t I have had t h o s e  ICU  N u r s e s and t h e B r a i n  Dead  Patient 74  t h o u g h t s t h e more t h a t I have worked w i t h donor p a t i e n t . I have. Another  participant  transplantation  indicates  some o f t h e s e  support f o r  but q u e s t i o n s w h e t h e r  t h e end j u s t i f i e s t h e  means. P. Anyway i t ' s a l m o s t t r e a t i n g a b r a i n dead ALTHOUGH I am f o r t h e and f e e l ok a b o u t you a l i t t l e disrespectful terms o f numbers.  feels a l i t t l e disrespectful p a t i e n t f o r organ d o n a t i o n . end r e s u l t . I agree with that know d o i n g i t b u t i s a l m o s t seems t o j u s t be t r e a t i n g t h i s body i n  R. I'm j u s t w o n d e r i n g what you meant by a disrespectful.  little  P. I g u e s s i t ' s t h e l i k e I'm f e e l i n g t h a t t h i s i s j u s t a c o n t a i n e r t h a t I am l o o k i n g a f t e r now and [ p a u s e ] I d o n ' t know t h e r e i s j u s t a b i t o f c o n f l i c t t h e r e now. And y e t t o j u s t be l i k e i t w o u l d n ' t b o t h e r me a b i t l i k e I say t o comb t h e i r h a i r even t h o u g h I know t h e y ' r e g o i n g t o go i n a h a l f an hour t o be an o r g a n donor. L i k e I would s t i l l want t o do t h o s e t h i n g s and to n o t I d o n ' t know how t o . R. I s i t t h e t h o u g h t t h a t y o u ' r e c a r i n g f o r t h i s b r a i n dead p a t i e n t f o r somebody e l s e and n o t f o r t h e p a t i e n t ? I s t h a t what's d i s r e s p e c t f u l o r P. I g u e s s i t ' s l i k e u s i n g somebody l i k e I'm g o i n g t o use t h i s p e r s o n . Or t h i s c o n t a i n e r I'm g o i n g t o use i t and maybe I q u e s t i o n do I have a r i g h t t o u s e i t . You know have I g o t a r i g h t t o use l i k e I d o n ' t use p e o p l e when t h e y ' r e l i v i n g . And even though t h i s i s j u s t a c o n t a i n e r l i k e j u s t a body t h e r e i s s t i l l s o m e t h i n g t h e r e t h a t b o t h e r s me a l i t t l e a b o u t u s i n g i t . . . Y e a h i t ' s j u s t l i k e u s i n g j u s t u s i n g somebody. Although i t i s f o r a good means t h a t t h e y a r e b e i n g u s e d . Yeah I d o n ' t know how e l s e t o p u t t h a t one. For  another  transplant benefit from  participant  recipient  i s a t odds w i t h  has t o be d e r i v e d .  the b r a i n  dead  the d e s i r e  patient.  That  to b e n e f i t  the  t h e manner i n w h i c h t h e  i s , the removal or organs  ICU  N u r s e s and t h e B r a i n  Dead  Patient 75  P. Oh t h e h a r d e s t t h i n g I t h i n k r e a l l y and t r u l y i s s e n d i n g t o t h e OR t h e d o n o r . I t h i n k t h a t i s the h a r d e s t t h i n g I do. B e c a u s e w e l l how do you d e s c r i b e that? What c a n you s a y a b o u t t h a t ? . . . I t ' s s o r t o f l i k e I j u s t s o r t of f e e l l i k e s a y i n g to the p a t i e n t " L i k e I'm r e a l l y s o r r y we have t o t a k e your o r g a n s b u t we d o n ' t want t o p u t them i n t o t h e ground do we? And so t h e y ' l l t o o t you o f f t o t h e OR and p u t them o u t you know." You s e e what I'm t r y i n g t o say? A similar discord  i s apparent  i n the f o l l o w i n g  excerpt.  P. I d o n ' t know where i t comes f r o m b u t I t e n d t o f i n d t h a t a l i t t l e b i t on t h e s q u e a m i s h s i d e , t o t h i n k t h a t t h e y a r e g o i n g t o t a k e them [ o r g a n s ] o u t and t o p u t them i n t o someone. I d o n ' t know where t h a t b i t o f s q u e a m i s h comes f r o m . . . a n d I t h i n k i t ' s I mean I t h i n k i t ' s a v e r y n e c e s s a r y t h i n g and i t ' s b r o u g h t a l o t o f b e n e f i t t o some p e o p l e . I t ' s j u s t v e r y t r a g i c t h a t we have t o t h a t i t happened w i t h a d e a t h o f u s u a l l y a young h e a l t h y p e r s o n . The  transcripts also  physically  demanding  and time  amount o f time r e q u i r e d conflict the  brain  with dead  indicate  that  consuming.  to maintain  care i s  The c a r e  failing  the p a r t i c i p a n t ' s d e s i r e patient's  donor  organs  and t h e is in  t o be s u p p o r t i v e  to  family.  P. L i k e he was g o i n g t o be g o i n g up t o s u r g e r y you know up t o t h e OR and she [ p a t i e n t ' s w i f e ] was q u i t e composed b u t she s a i d " I d o n ' t want t o l e a v e . I know when I l e a v e he i s g o i n g t o go. L i k e you w i l l t a k e him away and I j u s t d o n ' t want t o l e a v e . I know t h e r e i s n o t h i n g t h a t I c a n do o r t h a t you c a n do b u t i t ' s j u s t I c a n ' t l e a v e . " . . . I f e l t c o m f o r t a b l e enough w i t h t h e f a c t t h a t he was b r a i n dead b u t a t t h e same t i m e j u s t d a n c i n g i n t h e back knowing t h a t I g o t t o g e t d o i n g a l l t h i s work you know. L i k e w h i c h was s o r t o f stomach t u r n i n g b e c a u s e you want t o spend more time w i t h h e r a t t h i s p o i n t and y e t you know you've g o t t o s t a r t moving f ast.  P. I t g e t s v e r y f r u s t r a t i n g a t t i m e s when you a r e l o o k i n g a f t e r a p a t i e n t t h a t ' s b r a i n dead and t h e y become v e r y u n s t a b l e o r t h e y go i n t o f u l l DI o r  ICU  N u r s e s and t h e B r a i n  Dead  Patient 76  s o m e t h i n g and y o u ' r e v e r y v e r y busy a t t h a t p a r t i c u l a r time where y o u ' r e c h a s i n g t h e u r i n e and y o u ' r e h a n g i n g IVs l e f t , r i g h t and c e n t e r . P e r h a p s t h e y need a l o t o f b l o o d work based on t h e i r w h a t e v e r and you d o n ' t f e e l t h a t you have t h e time t o spend w i t h t h e f a m i l y . That r e a l l y b o t h e r s me a l o t and b e c a u s e I f e e l t h a t they're at s u c h l o s s t h a t they need t h a t s u p p o r t now more t h a n at a n y t i m e a t a l l . And w i t h o u r c u r r e n t n u r s i n g p r o b l e m as i t i s I sometimes f e e l t h a t I'm n o t a b l e t o p r o v i d e t h a t s u p p o r t f o r them t h a t I w i s h I c o u l d have...But I f e e l that I t h i n k i t ' s very u n f o r t u n a t e i f t h e y ' r e n o t a l l o w e d t h a t time t o g r i e v e w i t h you o r i f t h e y have q u e s t i o n s t h a t they j u s t s o r t o f t h i n k o f a l l of a sudden and t h e y want t o d i s c u s s t h a t w i t h you t o make them f e e l b e t t e r . . . T h a t you f e e l t h a t y o u ' r e h u s t l e b u s t l e a t t h e b e d s i d e so much t h a t maybe what t h e y [ f a m i l y ] need i s j u s t an arm a r o u n d them and s i t t i n g down w i t h a box o f K l e e n e x and l e t t i n g them j u s t have a g r e a t c r y b u t a l o t o f time you d o n ' t have t h a t time and t h a t was f r u s t r a t i n g f o r me a t t i m e s . This family  nurse a l s o  c a n make c a r e  i n d i c a t e s that of the b r a i n  the presence  dead  donor  of the  difficult.  P. I t h i n k when t h e y s t a y and want t o be a t t h e b e d s i d e I f i n d i t i s a l i t t l e b i t more d i f f i c u l t b e c a u s e you c a n ' t I f i n d you c a n ' t be q u i t e as e f f i c i e n t i n my p r e p a r a t i o n f o r t h e OR. And w i t h f a m i l y members t h e r e i t i s e x c u s e me, e x c u s e me and y o u ' r e w a l k i n g a r o u n d the b e s i d e and y o u ' r e t r y i n g t o send s p e c i m e n s o f f and d o i n g t h e p r e o p c h e c k l i s t and sometimes t h e y ' r e r e a d y to go t o t h e OR r i g h t now or i t ' s been d e l a y e d . I find i t i s a l i t t l e e a s i e r when t h e y ' r e n o t a t t h e b e d s i d e too. The  following  conflict  that  designated nursing  transcript  exists  of the b r a i n  members a r e s t i l l  evidence  f o r one p a r t i c i p a n t  the t r a n s p l a n t  care  provides  recipient dead  of the  when she has  as t h e r e a s o n  patient  f o r her  but the f a m i l y  present.  P. We d o n ' t e n c o u r a g e them [ t h e f a m i l y ] t o s t a y u n t i l t h e y [ t h e b r a i n dead p a t i e n t ] r o l l i n t o t h e OR o r w h a t e v e r . . . I d o n ' t mind i f t h e y s t a y f o r a w h i l e b u t I mean t e n o r t w e l v e h o u r s yeah i t i s p r o b a b l y b e t t e r b e c a u s e my f o c u s has changed a t t h a t p o i n t and I l i k e  ICU N u r s e s  and the  Brain  Dead  Patient 77  to be s e n s i t i v e to t h e i r needs but I am d o i n g t h i n g s a t t h a t p o i n t f o r somebody e l s e [ t h e t r a n s p l a n t recipient] I am not r e a l l y d o i n g i f f o r t h e i r f a m i l y member a t that p o i n t . I am not d o i n g i t f o r them. Just for somebody e l s e . Though the donors,  it  a number of programs. of  is  participants  evident  the  that  transplant  these  participants  For i n s t a n c e ,  provide  one  the  actions  care  oppose  hold regarding participant  for  brain  the  dead  beliefs  transplantation  questions  the  aim  programs.  P . I t h i n k d o n a t i o n programs a r e a l l f i n e and d a n d y . I t h i n k we have a l o t o f i r o n i n g out to d o . . . I t h i n k they a r e t r y i n g to meet t h e i r numbers so t h a t they can meet t h e i r budget and get the same budget n e x t y e a r w h i c h I'm not s u r e t h a t I a g r e e w i t h but R. By t r y i n g to meet too much g o i n g on?  their  number do you t h i n k  there  is  P . Oh y e a h . I t ' s a l l c r a p r i g h t now to be h o n e s t w i t h y o u . . . I t h i n k i t ' s you know " W e l l t h i s a l m o s t f i t s h e r e , l e t ' s put i t i n t h i s c h e s t you know and we w i l l just stuff i t in here." And our f i r s t donor t h a t we l o o k e d a f t e r who was h e r e f o r f o u r months and gee funny enough she went i n t o the DTs p o s t o p . W e l l you know I t h i n k t h o s e k i n d of s c r e e n i n g p r o c e d u r e s s h o u l d be done and she was d i s c h a r g e d once from the h o s p i t a l and went home and smoked f o u r p a c k s of smokes and came back dn b e c a u s e she R.  Donor you  said?  P. R e c i p i e n t . We c a l l them our f i r s t donor l i k e meaning she was a r e c i p i e n t of a d o n o r . Ok? And t h a t whole s c e n e I t h i n k put a l o t of us o f f the whole h e a r t lung program. R.  So she  was  back  after  P 6 . Oh yeah and she ended up d y i n g . n o n c o m p l i a n t and she d i d n ' t want to they l e t h e r d i e .  She was l i v e any more.  So  ICU  N u r s e s and t h e B r a i n  Dead  Patient 78  Another little  p a r t i c i p a n t f e e l s that  b i t more h u m a n i t y  there  t o come i n t o  i s a need  t h e donor  f o r "a  system."  P. And I t h i n k we a r e sometimes c r o s s i n g l i n e s t h a t we s h o u l d n ' t c r o s s and I t h i n k t h e t e c h n o l o g y i s m a r c h i n g ahead o f t h e e t h i c s and I t h i n k t h a t sometimes we have to slow down t h e t e c h n o l o g y t o d e a l w i t h t h e e t h i c s a bit. Cause sometimes you c a n go t o o f a s t t o o f a r . And l e t t h e r e s t o f them, c a t c h up b e c a u s e t h e p u b l i c doesn't understand the i s s u e s . Cause t h e p u b l i c r e a l l y doesn't understand the i s s u e s . They j u s t go: " I s n ' t i t wonderful. Look we've s a v e d a n o t h e r c h i l d . " R. So by b r i n g i n g more h u m a n i t y i n t o t h e t r a n s p l a n t a t i o n you mean l o o k i n g more a t t h e e t h i c s o f it? P. L o o k i n g more a t t h e e t h i c s and l o o k i n g more a t t h e r a m i f i c a t i o n s o f you p u t a l i v e r i n t o one c h i l d b u t t h e y may p u t f o u r l i v e r s i n t o one c h i l d . Is that right? Phenomenal phenomenal c o s t s . Emotional costs on t h e f a m i l y . And t h e n t h e u l t i m a t e argument i s s h o u l d you be p u t t i n g f o u r t i m e s t h e c o s t o f t h a t s u r g e r y i n t o one c h i l d v e r s u s s p r e a d i n g i t o u t more? I d o n ' t know. One p a r t i c i p a n t a l s o of  dissonance  receives  r a i s e s the i s s u e  to e x i s t i f the i n t e n s i v e  f o r the p o t e n t i a l  care  unit  also  recipients.  P. I t ' s p r o b a b l y j u s t as w e l l t h a t we d o n ' t g e t t o s e e the r e c i p i e n t b e c a u s e we u s u a l l y we're a d i f f e r e n t u n i t but I mean t h e r e w i l l come a time when we w i l l s e e them b e c a u s e t h e l i v e r s w i l l come back t o us and so we w i l l see t h e p a t i e n t t h a t y o u ' r e w o r k i n g so h a r d t o save and t h e n i s b r a i n dead and i s s e n t t o t h e OR. And you w i l l see t h e new p a t i e n t come back and q u i t e o f t e n they're so s i c k you w i l l s e e t h e p a t i e n t w a i t i n g f o r t h e l i v e r as w e l l so t h a t ' s a c h a n c e you w i l l have t o t a k e . R. I n what way? P. W e l l you w i l l know who g o t t h e l i v e r I mean you w i l l know t h e p a t i e n t t h a t went t o t h e OR and was b r a i n dead and d o n a t e d and you w i l l a l s o know t h e p a t i e n t t h a t r e c e i v e d the l i v e r .  ICU  N u r s e s and t h e B r a i n  Dead  Patient 79  R. W i l l t h a t patients?  a f f e c t how you f e e l  P. No I d o n ' t t h i n k s o . of a s e n s i t i v e a r e a .  that the  I just find  e i t h e r of the  i twill  Professional  r e s p o n s i b i l i t y and p e r s o n a l  The  o f a number  accounts  their family  their  about  be a b i t  needs.  of the p a r t i c i p a n t s i n d i c a t e  p r o f e s s i o n a l r e s p o n s i b i l i t y t o be s u p p o r t i v e i s often  own e m o t i o n a l  i n opposition  to the nurses  to  meeting  needs.  P. I d e a l w i t h i t much b e t t e r now t h e n I u s e t o b e c a u s e I t h i n k t h a t I have d e a l t w i t h i t so o f t e n t h a t I'm a c t u a l l y f i n e u n t i l t h e y [ t h e f a m i l y ] hug me. When t h e y hug me I hug them back and t h e n I have t o k i n d o f b i t e t h e i n s i d e o f my mouth o r s o m e t h i n g b e c a u s e I c a n f e e l my l i p s s o r t o f q u i v e r i n g . I f they're i n tears I l i k e t o bawl my e y e s o u t w i t h them but I f e e l t h a t ' s not my r o l e a t t h a t p a r t i c u l a r t i m e . I have t o be t h e s t r o n g p e r s o n f o r them and I c a n have my time l a t t e r when I change o u t o f my u n i f o r m o r w h a t e v e r . I f I'm a b l e t o be t h e r e f o r them t h a t ' s g r e a t . Sometimes i t ' s a heavy h e a r t e d d r i v e home and I t r y t o shake t h a t o f f by t h e time I open t h e f r o n t door and some days a r e b e t t e r than o t h e r s . One p a r t i c i p a n t d e s c r i b e s the  family  she  i s able  i s present  the d i f f e r e n c e  and when t h e y  t o meet h e r own  are not.  f o r h e r when In the l a t t e r  needs.  P. You do f e e l r e a l l y s a d and sometimes you c r y w i t h the f a m i l y and a l l t h i s b u t you know I g u e s s b e c a u s e we're t r y i n g t o make t h e f a m i l y f e e l b e t t e r t h a t you don't. You d o n ' t want t o l i k e s t a r t c r y i n g your e y e s out and be worse t h a n t h e f a m i l y t y p e o f t h i n g . . . b u t I remember o n c e . . . I j u s t s a t t h e r e and h e l d h i s hand. He d i d n ' t have a f a m i l y , he was d y i n g and I j u s t . . . I d o n ' t know t h e r e was no f a m i l y so I was t h e r e I a l o n e i n t h e room and I j u s t h e l d h i s hand and I had t e a r s i n my e y e s and I c r i e d a b i t and I g u e s s your e m o t i o n s come f o r w a r d t h e n and i t c o u l d be b u i l d up from o t h e r things as w e l l and you know b u t t h e n t h a t was t h a t .  ICU  N u r s e s and t h e B r a i n  Dead  Patient 80  One n u r s e to  see the p a t i e n t  fourth is  describes  shift  evident  before  again  i n order  from  a conflict  where she does n o t want  but r e q u e s t s  t o meet  the p a t i e n t  fora  t h e needs o f t h e f a m i l y .  the t r a n s c r i p t  that  the f a m i l y  It  needs came  the nurse's.  R. You had i n d i c a t e d t h a t t h i s was your and you j u s t want t h a t body t o go.  fourth  shift  P. W e l l I w i t h t h a t p a r t i c u l a r p a t i e n t I f e l t we had gone t h e whole r o u t e . We had s u p p o r t e d t h e f a m i l y when he f i r s t came i n . We had t a k e n them t h r o u g h t h e i d e a t h a t he might n o t l i v e and t h e n he became b r a i n dead and t h e n we j u s t wanted him t o go and a t t h a t p o i n t t h e r e was n o t h i n g more t h a t we c o u l d do f o r t h e f a m i l y and we wanted t h e p a t i e n t t o l e a v e . I wanted t h e p a t i e n t t o go. R. But you s t i l l  requested  that  fourth  day j u s t  P. B e c a u s e I knew them and I knew t h e y wanted me t o be t h e r e and a l s o i f I had s e e n them and I was i n t h e u n i t I d i d n ' t want them t o t h i n k t h a t I was a v o i d i n g HIM o r them. So I j u s t wanted t o do i t t h a t way. Another  participant  o c c u r s when t h e f a m i l y go  to the o p e r a t i n g  describes  waits  the i n t e r n a l  f o r the b r a i n  dead  room and she does n o t want  discord  that  p a t i e n t to them  there.  P. I t was e a s i e r t h a t t h e f a m i l y wasn't t h e r e . But i t d o e s n ' t a l w a y s work o u t t h a t way sometimes t h e y want t o s t a y w i t h t h e p e r s o n u n t i l t h e y go t o t h e o p e r a t i n g room. R. And how do you f e e l  a t those  times?  P. I t ' s i t ' s I c a n o n l y d e s c r i b e i t as f e e l i n g s t r a n g e and removed b e c a u s e h e r e i s t h e f a m i l y member s i t t i n g w i t h someone who i s d e c l a r e d b r a i n dead and w a i t i n g t o go f o r s u r g e r y t o t a k e t h e i r body p a r t s away and I g u e s s i t d o e s n ' t a g r e e w i t h my i n n e r f e e l i n g l i k e how t h a t p a t i e n t has d i e d . I d o n ' t know i f I would do t h e same t h i n k i f t h a t was my f a m i l y , member i n t h e b e d . But I d o n ' t I g u e s s I d o n ' t know what t o s a y t o them. You know when t h e p e r s o n i s n o t b r a i n dead and you a r e  ICU  N u r s e s and t h e B r a i n  Dead  Patient  81 t a l k i n g t o t h e f a m i l y and you a r e i n t e r a c t i n g w i t h them and t h e y ' r e u s u a l l y t e l l i n g you a b o u t t h i s p e r s o n . I a l m o s t d o n ' t know what t o s a y a f t e r t h e y ' r e j u s t s i t t i n g t h e r e w a i t i n g t o go f o r s u r g e r y . Maybe i t ' s b e c a u s e I f e e l awkward. I d o n ' t know i f i t ' s b e c a u s e I a l r e a d y f e e l t h a t they d i e d o r maybe i t ' s j u s t b e c a u s e I don't know what t o say t o t h e v i s i t o r s . And t h e n what do you s a y when t h e s u r g e o n s come from t h e o p e r a t i n g room and e v e r y o n e comes and t h e y have n e v e r seen t h i s f a m i l y member and t h e y u s u a l l y you know t h e r e i s u s u a l l y s i x o f them o r s o m e t h i n g and t h e y come and t h e y want n i n e t y - n i n e d e t a i l s about t h e p a t i e n t and how s t a b l e he's been and t h e y a r e u n h o o k i n g him from t h e m o n i t o r and e v e r y t h i n g and [ p a u s e ] . How does t h a t f a m i l y member f e e l ? Maybe i t ' s j u s t b e c a u s e I f e e l awkward a b o u t t h e whole s i t u a t i o n . At  times  overwhelming  the emotional that  stress  she i s u n a b l e  f o r the nurse  t o meet  may be so  t h e needs o f t h e  family. P. Now t h a t I have been h e r e i n ICU f o r q u i t e a w h i l e I seem t o d e a l w i t h f a m i l i e s b e t t e r than I d i d i n i t i a l l y . When a young g i r l I had a c o u p l e o f y e a r s ago I t o t a l l y c o u l d not d e a l with the f a m i l y a t a l l . I l e t the c h a r g e n u r s e do t h a t . I took c a r e o f t h e p a t i e n t . She took c a r e of the f a m i l y . I c o u l d n ' t even l o o k them i n the e y e . They were a l s o um L a t i n b a c k g r o u n d you know S p a n i s h and v e r y e m o t i o n a l and j u s t I had t o c l o s e m y s e l f o f f . I p r o b a b l y would have ended up c r y i n g m y s e l f as w e l l w h i c h p r o b a b l y maybe t h a t would have been a good t h i n g f o r them t o s e e t h a t I c o u l d be e m o t i o n a l as w e l l i n s t e a d o f b e i n g a b l o c k o f i c e . But f o r me a t t h a t time when I was f i r s t new t o t h e ICU i t h e l p e d me d e a l w i t h t h e p a t i e n t . Now I c a n c r y i n f r o n t of the f a m i l y . I t d o e s n ' t b o t h e r me. And I t h i n k t h a t i t ' s n i c e f o r them t o s e e t h a t we're n o t icebergs. T h a t we're c a p a b l e o f e m o t i o n and t h a t we're not j u s t m a c h i n e s . Interpersonal  Dissonance  When t h e n u r s e s ' and  behaviour  interact following  then  oppose  beliefs, those  interpersonal  sections  will  values,  opinions,  knowledge  o f i n d i v i d u a l s w i t h whom dissonance  present  occurs.  data which  they  The  demonstrate  the  ICU  Nurses  and t h e B r a i n  Dead  Patient 82  external  dissonance  families,  that  physicians,  o c c u r s between  t h e n u r s e and  t h e PORT team and even h e r own n u r s i n g  colleagues. The  nurse  and t h e f a m i l y .  The  nurse  and t h e f a m i l y  perspective patient. from  Their  their  attachment family of  to the s i t u a t i o n  unique  their  involving  own  distinctive  the b r a i n  dead  i n c o g n i t i o n s and a c t i o n s  knowledge,  to the p a t i e n t .  usually  brain  differences  bring  evolve  p e r s o n a l e x p e r i e n c e s and Due t o t h e s e  has g r e a t e r d i f f i c u l t y  c h a r a c t e r i s t i c s the  a c c e p t i n g the concept  death.  P. The p u b l i c has a r e a l l y h a r d time knowing t h e difference. They have a h a r d time u n d e r s t a n d i n g what b r a i n d e a t h i s . They come i n h e r e and t h e y s e e t h e i r l o v e d one on a b r e a t h i n g machine and t h e y l o o k peaceful. They l o o k t h e same as they were i n maybe t h e day b e f o r e when they w e r e n ' t b r a i n dead and t h e y c a n ' t understand that d i f f e r e n c e . They don't r e a l l y understand the concept. It  i s this  diagnosis  of b r a i n  interpersonal The  inability  death which  dissonance  dissonance  personal stress  following  case  fact  that  their  that  she was b e i n g c a r e d was g o i n g  lies  shared  behind  involving  the nurse a family  e i g h t e e n year  much o f t h e  by t h e n u r s e  between t h e n u r s e  resulting  she  t o a c c e p t and comprehend t h e  and t h e f a m i l y  feels  who  and t h e f a m i l y . and t h e  i s evident i n the  c o u l d not accept the  o l d daughter  f o r by a n u r s e  was b r a i n  dead o r  who d i d n o t b e l i e v e  t o go home.  P. But t h e f a m i l y t h e y j u s t wanted h e r b a c k . They d i d n ' t c a r e what she was. They wanted j u s t t o have h e r  ICU  N u r s e s and t h e B r a i n  Dead  Patient 83  body back. L i k e t h e y d i d n ' t c a r e how b a d l y i n j u r e d she was o r what um she t u r n e d o u t t o be. They j u s t wanted her home. T h a t f a m i l y was r e a l l y h a r d t o d e a l w i t h b e c a u s e you know l i k e t h e y had been t o l d t h a t t h e r e was v e r y l i t t l e hope and t h e r e was no hope. And t h e y s a i d t o me: "So you know l i k e i f t h e r e i s no hope what a r e you d o i n g h e r e ? " You know and i t was l i k e ugh. And I s a i d w e l l i f she had any hope t h i s was t h e o n l y p l a c e t h e r e was. And t h a t was t h e o n l y f a m i l y t h a t ' s r e a l l y fought. They a l l f o u g h t i t b u t t h a t one was r e a l l y a g g r e s s i v e t o w a r d s me. " L i k e why a r e you d o i n g t h i s ? " or you know l i k e " I f you b e l i e v e t h a t what a r e you doing here? Get away and g e t someone e l s e t h a t t h i n k s she c a n g e t b e t t e r o r w h a t e v e r . " R. And how d i d t h a t  make you f e e l ?  P. R o t t e n . L i k e i t was l i k e oh! I t made you t h i n k a b o u t what you were d o i n g b u t I you know f e l t l i k e my answer was t h e o n l y one I had l i k e she came i n she wasn't gone. We d i d e v e r y t h i n g we c o u l d . I f t h e r e was a chance f o r h e r t o s u r v i v e we were g i v i n g i t t o h e r . . . T h e y wanted h e r home. They wanted h e r . They d i d n ' t c a r e i f she c o u l d do n o t h i n g b u t l i e i n t h e b e d . They j u s t d i d n ' t want t o l o s e h e r and b e c a u s e I was r e i n f o r c i n g how p o o r l y she was d o i n g and t h a t she was g e t t i n g worse and worse and you know t h a t b e c a u s e I was g i v i n g them no hope. T h e y ' r e s a y i n g : " W e l l why a r e you here? Why a r e you even b o t h e r i n g t h e n ? " I t was j u s t t h e i r g r i e f I t h i n k and i t was f i g h t i n g back a t me b e c a u s e she s t i l l i s a l i v e f o r t h e f a m i l y and she was i t took h e r a few days t o become b r a i n d e a d . T h e r e was j u s t a r e a c t i o n you know. R. I s t h a t  because  P. They wanted In insists her tell  another that  son.  you w e r e n ' t  to hear  situation,  only  telling  them what...  so they  were s t r i k i n g  a brother  of a b r a i n  he i s t o t e l l  However, t h e b r o t h e r  back.  dead  man  h i s mother o f t h e d e a t h o f i s unable  to b r i n g  himself  to  h i s mother and when t h e mother a r r i v e s she i s unaware  her  son i s dead.  and  t h e n u r s e when t h e n u r s e  her  son's  death.  A discord  e x i s t s between t h e s u r v i v i n g s o n attempts  to t e l l  t h e mother o f  ICU  N u r s e s and t h e B r a i n  Dead  Patient  84  P. She [ t h e m o t h e r ] was s a y i n g : "Oh w e l l tomorrow he w i l l be f i n e and he f e e l s so n i c e and warm." and a l l t h i s r o t and so I s o r t o f k n e l t down b e s i d e h e r . L i k e I'm down low a l m o s t a t t h e bed frame l e v e l and I'm l o o k i n g up a t h e r and he [ t h e b r o t h e r ] i s t r y i n g t o c a t c h my f a c e so t h a t I w o u l d n ' t s a y a n y t h i n g t o w h i c h I s a i d : "What do you know a b o u t what's wrong w i t h your son?" And she s a i d : "Oh w e l l he's j u s t had a headache or s o m e t h i n g o r o t h e r . " And I s a i d "No." I explained what had happened and t h a t he had a v e r y bad b l e e d and he e s s e n t i a l l y was gone. And she s a i d : "Oh no, he i s s t i l l breathing." And so I had t o e x p l a i n t o h e r a b o u t the v e n t i l a t o r and I s a i d i f I t o o k t h a t away h i s body w o u l d n ' t work and she s a i d s o m e t h i n g e l s e and i n t h e mean time t h e s o n i s r a d i a t i n g t h i s : "Don't you d a r e t e l l her" business. You c o u l d j u s t f e e l i t . So she a s k e d a few more q u e s t i o n s and t h e n she s a i d s o m e t h i n g and I s a i d : "Your son i s d e a d . Your son d i e d l a s t night." And she s a i d no a c o u p l e o f t i m e s and t h e n she s a i d : " W e l l y o u ' r e w i t h your dad now" b e c a u s e t h e dad had d i e d as w e l l . And o f f she went o f f t o t h e back room. And t h e son was j u s t r i g h t o f f p i s s e d o f f , right. And t h a t what was h a r d e r t h e n t a k i n g c a r e o f him [ t h e b r a i n dead p a t i e n t ] , R. How d i d you a c t u a l l y f e e l g o i n g on?  at that  time  this  was  P. I was p i s s e d o f f b e c a u s e we had a v e r y lengthy d i s c u s s i o n w i t h t h e f a m i l y t h a t a f t e r n o o n and t h e r e s p i r o l o g i s t had, we made t h i s agreement t h a t t h e s o n would t a l k t o h i s mom. And I mean t h a t was t e r r i b l e f o r h e r you know t o come i n and i t w o u l d n ' t have made i t easy whether she had h e a r d i t i n t h e a i r p o r t o r whether she h e a r d i t h e r e . But she came a l l t h e way from t h e a i r p o r t w i t h t h e s e e x p e c t a t i o n s o f t h a t he was g o i n g t o g e t b e t t e r and l i k e he t h e n d i d n ' t do a n y t h i n g to i n t e r v e n e w i t h h e r . And so I was r e a l l y p i s s e d o f f . R e a l l y p i s s e d o f f . . W e l l b u t I mean t h e r e was n o t much t h a t you c o u l d r e a l l y do a b o u t t h a t . . . . i t would have been d i f f e r e n t t o t e l l h e r i f you knew you were g o i n g to t e l l h e r b e c a u s e your a p p r o a c h i s a l i t t l e different. You know what I mean? Where you d o n ' t walk i n t o i t as c o l d as you do i n t h a t s i t u a t i o n . L i k e you d o n ' t even have time t o s o r t o f p r e p a r e y o u r s e l f t o t e l l them l e t a l o n e h a n d l e . . . s e e where i t ' s g o i n g t o go. I t ' s r e a l l y a v o l a t i l e s i t u a t i o n a t t h a t moment b e c a u s e you've g o t t h e son whose f u r i o u s and you've g o t a mother whose j u s t c l i n g i n g t o hope and t h e n b e c a u s e we d o n ' t u s u a l l y n o t t h e n u r s e s we d o n ' t u s u a l l y t e l l I  ICU  N u r s e s and t h e B r a i n  Dead  Patient 85  mean I t h i n k I ' v e t o l d p e r s o n i s gone. When t h e f a m i l y regarding dissonance  organ  three  people  and t h e n u r s e h o l d  transplantation  i s present.  This  then  that  their  opposing  family  beliefs  interpersonal  i s evident  i n the f o l l o w i n g  account. P. L i k e I'm s a y i n g b e f o r e u s u a l l y t h e r e i s a b i t o f a n g e r w i t h . . . t h e b r a i n dead p a t i e n t t h a t t h e y d o n ' t want t o d o n a t e o r g a n s f o r some... p a r t l y sometimes t h e f a m i l y j u s t h a s n ' t come t o a d e c i s i o n b e c a u s e t h e y don't r e a l l y know what i t means and t h e o t h e r one i s a l m o s t l i k e maybe i t ' s been a waste o r why why d o n ' t they u n d e r s t a n d about organ d o n a t i o n . Another  informant  when she i s p e r f o r m i n g will she  consent  describes  the d i s s o n a n c e which  care  t h e hope t h a t  to donation  i s providing  with  and t h e f a m i l y  occurs  the f a m i l y  i s questioning  why  the c a r e .  P. I t h i n k i t was eye c a r e . Cause t h e whole r e a s o n I was d o i n g t h a t was b e c a u s e i n c a s e t h e y d o n a t e d I wanted make s u r e h i s c o r n e a s were ok. And I t h i n k my r e s p o n s e was t h a t i t was a r o u t i n e p r o c e d u r e t h a t we d i d f o r e v e r y o n e t h a t was on a v e n t i l a t o r o r s o m e t h i n g l i k e that. And w i t h o u t I d i d n ' t want t o s a y : " B e c a u s e I'm h o p i n g t h a t y o u ' r e g o i n g t o be d o n a t i n g h i s c o r n e a s t h e r e f o r e I want t o make s u r e t h e y s t a y m o i s t and i n good c o n d i t i o n . " I t h i n k I s a i d i t was b e c a u s e t h i s was a n o r m a l p r o c e d u r e f o r e v e r y o n e on a v e n t i l a t o r o r something l i k e t h a t . Not t h a t your e y e s g e t d r y i f y o u ' r e on a machine b u t I t h i n k I j u s t s o r t o f i n c o r p o r a t e d i t and t h a t seemed t o s a t i s f y them. Another aware o f what  instance  of dissonance  the p a t i e n t ' s  i s when t h e n u r s e i s  outcome w i l l  be and t h e f a m i l y  is not. P. I d o n ' t know i f any one t h i n g i s t h e h a r d e s t thing to do. I t would p r o b a b l y be s u p p o r t i n g t h e f a m i l y o r d e a l i n g w i t h t h e f a m i l y d u r i n g t h a t phase when you a s a  ICU  N u r s e s and t h e B r a i n Dead  Patient 86  nurse t h i n k t h i s person i s going t h e y don't know i t y e t . R. And you c a n ' t  t o be b r a i n  dead b u t  really...  P. You c a n ' t come o u t and s a y : " W e l l gee I t h i n k t h i s p e r s o n i s g o i n g t o be b r a i n d e a d " o r w h a t e v e r . You have t o keep t h a t b i t o f i n f o r m a t i o n t o y o u r s e l f . I t h i n k t h e h a r d e s t t h i n g i s i s t h a t phase b e c a u s e you have t o a l l o w them t o have some hope even though you y o u r s e l f a r e t h i n k i n g : "Gee t h e r e i s p r o b a b l y no way t h a t he w i l l e v e r r e c o v e r . " The  nurse  and t h e p h y s i c i a n .  The  discord  which  physician  i s related  the  dead  brain  delegated  physician  counter With  is  an u n n e c e s s a r y  patient decision  include  and t h e management o f  on t h e n u r s e s ' decision-making,  i n management and ' i n a p p r o p r i a t e '  Each of these  to t h e i r  regard  of the medical  These a s p e c t s  management l e a d s t o t h e n u r s e s are  the nurse  w h i c h have an i m p a c t  of approach  actions.  between  to a s p e c t s  patient  functions.  consistency  occurs  beliefs,  components o f m e d i c a l  performing  f u n c t i o n s which  v a l u e s or knowledge.  to decision-making  the nurses  p r o l o n g a t i o n of v i t a l  believe  there  f u n c t i o n s i n a dead  due t o a h e s i t a n c y by t h e p h y s i c i a n t o make a w h i c h would  terminate  life  support.  P. L i k e why a r e we d o i n g t h i s ? Especially i f i t i s somebody t h a t you know i s n o t g o i n g t o be used f o r o r g a n r e t r i e v a l and y o u ' r e j u s t w a i t i n g f o r them [ t h e p h y s i c i a n s ] t o p e r h a p s make a d i a g n o s i s o r s a y t h a t t h e r e i s n o t h i n g more t h a t we c a n do so s h u t o f f . Or why a r e t h e y w a i t i n g f o r t h i s t o go on and on? Because you know t h a t p h y s i c i a n d o e s n ' t l i k e making t h e s e decisions. So t h e y s i t on i t and t h e y w a i t u n t i l m o r n i n g o r w h a t e v e r and we know i t ' s n o t g o i n g t o g e t any b e t t e r . So why don't you j u s t g e t on w i t h i t and do i t now? That's f r u s t r a t i n g . That's hard to d e a l w i t h something l i k e t h a t . W e l l s i n c e t h e l a s t few  ICU  N u r s e s and t h e B r a i n Dead  Patient 87  y e a r s I g u e s s maybe we've [ t h e n u r s e s ] become more aggressive...and say: "This i s i t ! This i s black. This i s white. And t h e r e i s no i n between so make a d e c i s i o n and q u i t w a f f l i n g ! " And I w i l l go up t o them and I w i l l s a y t h a t and I d o n ' t c a r e i f i t i s t h e D i r e c t o r o f t h e u n i t o r what. But sometimes I t h i n k they need a l i t t l e p u s h ! The her  e x t e r n a l disharmony  questioning  black.  This  Several which  and h e r s t a t e m e n t  nurse  "This  i s evident i n  is i t !  This i s  i s white..." accounts  indicate interpersonal  i s r e l a t e d to not only  make a d e c i s i o n b u t a l s o family  for this  a hesitancy  dissonance  of the p h y s i c i a n to  to the p h y s i c i a n a l l o w i n g the  t o d e t e r m i n e whether  or not treatment  should  be  discontinued. P. I t was a t w e n t y - s e v e n y e a r o l d whose n o t e s d e c l a r e d him b r a i n dead on F r i d a y m o r n i n g . I came on, on Sunday m o r n i n g and was a s s i g n e d t o t h e p e r s o n , t h i s p a t i e n t . Ah you know l i k e I g o t r e p o r t ugh i t was l i k e WHAT ARE WE DOING THIS FELLOW HAS BEEN DEAD SINCE FRIDAY MORNING. You know l i k e I d i d n ' t even go n e a r t h e p a t i e n t u n t i l I t a l k e d t o t h e d o c t o r s and s a i d : " E x c u s s me what's g o i n g on h e r e ? What a r e we d o i n g ? " And t h e f a m i l y w e l l i n my o p i n i o n t h e f a m i l y was a l l o w e d a l i t t l e b i t t o o much l e e w a y . D o n a t i o n was o u t o f t h e q u e s t i o n , w h i c h was f a i r enough. I t i s e n t i r e l y up t o the f a m i l y . And i t r e a l l y d o e s n ' t make a whole l o t o f d i f f e r e n c e t o me. When you d e c i d e y e s o r no I f e e l t h a t i t i s e n t i r e l y up t o them and t h e r e i s no p r e s s u r e from a n y . . . t h e r e s h o u l d be no p r e s s u r e . But t h i s f a m i l y had an i n c r e d i b l e b e l i e f i n God. B e c a u s e God was g o i n g t o wake t h i s f e l l o w up and he was g o i n g t o get o u t o f bed and w a l k . And no one c o u l d shake t h a t . And so they would n o t l e t us t u r n o f f t h e v e n t i l a t o r . Not t h a t I t h o u g h t t h a t they s h o u l d have a c h o i c e b e c a u s e t h e r e i s no c h o i c e t h e p e r s o n i s g o n e . . . I l o o k e d a f t e r him a l l day and Monday he was s t i l l t h e r e and t h e n we had a change o f d o c t o r s and t h a t was t h e end o f t h a t n o n s e n s e . R. How would you d e s c r i b e i n on Sunday?  your  f e e l i n g s when you came  ICU  N u r s e s and t h e B r a i n Dead  Patient  88  P. W e l l l i k e d i s g u s t o r j u s t l i k e t h e r e i s NO POINT WE ARE NOT DOING ANYTHING HERE. You're w a s t i n g time, r e s o u r c e s , p r o l o n g i n g t h e f a m i l y . . . t h e hope o r whatever. They c a n ' t g e t a l o n g w i t h t h e i r l i v e s . Like i t i s j u s t a waste o f e v e r y t h i n g , o f e m o t i o n , o f e v e r y t h i n g you know. I d o n ' t want t o spend t h e day t u r n i n g and l o o k i n g a f t e r a p a t i e n t t h a t has been two days dead j u s t b e c a u s e t h e f a m i l y c a n ' t t u r n o f f t h e ventilator. They d o n ' t have a c h o i c e i n t h e m a t t e r . They l o s t t h e i r son when h i s head h i t t h e c u r b . . . W e l l yeah I g e t a n g r y when...you know t h a t y o u ' r e j u s t prolonging death. E v e r y b o d y knows t h a t b u t t h e f a m i l y wants you t o c a r r y on and I t h i n k t h e r e i s j u s t t o o much c h o i c e g i v e n t o t h e f a m i l y b e c a u s e i t ' s n o t f a i r to a s k someone. To g i v e them a c h o i c e when t h e r e i s n ' t a c h o i c e . . . T h e y ' v e l o s t t h e c h o i c e b e c a u s e we even we d o n ' t have a c h o i c e . We c a n p r o l o n g i t b u t we c a n n o t stop i t . Another physicians  nurse  delaying  voices  t h e same c o n c e r n s  the order  to d i s c o n t i n u e  regarding ventilation.  P. The p r o b l e m I have i s when t h e p a t i e n t i s c o n s i d e r e d b r a i n dead and t h e r e i s a d e l a y i n r e m o v i n g them from the v e n t i l a t o r . I n my o p i n i o n they [ t h e f a m i l y ] s h o u l d . be t o l d t h a t t h e p a t i e n t i s d e a d . They're [the p h y s i c i a n s ] t a k i n g him o f f t h e v e n t i l a t o r . The f a m i l y s h o u l d be t o l d t h i s . T h e r e s h o u l d n ' t be any room f o r : " I s i t ok i f we t a k e him o f f ? " That i s not a d e c i s i o n f o r them t o make...But I know t h e r e has been a few d e l a y s i n t a k i n g them o f f t h e v e n t i l a t o r and I r e a l l y f i n d i t d i f f i c u l t to d e a l with those d e l a y s . Once they a r e c o n s i d e r e d b r a i n dead, they have gone t h r o u g h a l l the t e s t s I t h i n k they s h o u l d be removed r i g h t now. That's the e t h i c s p a r t that I f i n d f r u s t r a t i n g . R. And so you d o n ' t f e e l t h e f a m i l y s h o u l d be g i v e n any f u r t h e r time when they have been t o l d t h e p a t i e n t i s b r a i n dead a n d . . P. No. I t h i n k they s h o u l d be removed from t h e v e n t i l a t o r and i f t h e f a m i l y wants t o come i n t h e n and v i e w t h e body t h a t ' s e x a c t l y what would happen i f a p e r s o n d i e d i n a r e g u l a r way on a f l o o r . I d o n ' t know what we a r e d e l a y i n g t a k i n g them o f f t h e v e n t i l a t o r f or.  ICU  N u r s e s and t h e B r a i n  Dead  Patient 89  If making  the p h y s i c i a n process  believe  brings  then c o n f l i c t  the f a m i l y  into  the d e c i s i o n  may a r i s e b e c a u s e  i t i s a r e s p o n s i b i l i t y that  the f a m i l y  some  nurses  does n o t  want. P. Um hum and a l l you know THEN you know b e c a u s e you t e n d t o have t o smooth o v e r t h e t r o u b l e d w a t e r s and b e c a u s e t h e . . . g o i n g back t o t h i s l a s t c a s e t h e y [ p h y s i c i a n s ] were t a l k i n g a b o u t t h e p a t i e n t becoming a no c o d e . He wasn't b r a i n dead y e t and t h e y s a t t h e r e and t a l k e d t o t h e f a m i l y a b o u t i t b u t t h e y ended up so I went i n on t h e c o n f e r e n c e and t h e r e were a b o u t s e v e n f a m i l y members and t h i s p h y s i c i a n . And t h e y ended up the p h y s i c i a n a l m o s t posed i t a b i t as a q u e s t i o n : " W e l l we a r e g o i n g t o make him a no c o d e . What do you think?" And o f c o u r s e t h e f a m i l y was j u s t i n t u r m o i l b e c a u s e t h e y c o u l d n ' t make t h a t k i n d o f d e c i s i o n and so the d o c t o r l e f t . And I must have s p e n t a b o u t a h a l f an hour w i t h them a f t e r w a r d s b e c a u s e I know t h e y w e r e n ' t happy w i t h t h e i s s u e t h a t he had r a i s e d and j u s t wanted to f i n d o u t why they w e r e n ' t happy. And so you g e t e a c h one t o t e l l y o u . You c a n s e e t h a t t h e r e i s s o m e t h i n g on t h e i r mind and um i t j u s t came o u t t h a t t h e y d i d n o t want t o have t o s a y : "Ok d o n ' t r e s u s c i t a t e him." B e c a u s e i n t h e i r mind he wasn't b r a i n dead y e t and t h e y d i d n ' t want t o f e e l l i k e t h e y were t u r n i n g him o f f w h i c h a l o t o f f a m i l y members... can you blame them? You c a n ' t blame them f o r n o t w a n t i n g t o t u r n someone off. I t d o e s n ' t m a t t e r t h a t he i s g o i n g t o d i e eventually. Two p a r t i c i p a n t s b e l i e v e decision relates  that  i s n o t so much a h e s i t a n c y more t o s i m p l y  not g e t t i n g  the l a c k  of a medical  t o make t h e d e c i s i o n b u t around  t o making t h e  decision. P. Why am I d o i n g t h i s ? I k n o w . . . t h e r e i s no p o i n t and sometimes I had a p a t i e n t t h a t you know i s b r a i n dead t h a t they [ t h e p h y s i c i a n s ] j u s t h a v e n ' t d e c l a r e d them b r a i n dead y e t . I t ' s t h e n i g h t time and t h e y w i l l be coming i n t h e m o r n i n g t o do t h a t . So you as y o u ' r e d o i n g t h e mouth c a r e and t h e back r u b s your t h i n k i n g t h a t t h i s i s r e a l l y a waste o f e n e r g y .  ICU  N u r s e s and t h e B r a i n  Dead  Patient 90  P. I f t h e p e r s o n n o t g o i n g t o be a donor and i s b r a i n dead and sometimes t h e y [ t h e p h y s i c i a n s ] keep on d o i n g t h i n g s when you know t h a t you know t h e y j u s t h a v e n ' t come a r o u n d and w r i t e t h e o r d e r s t o o r t h e y h a v e n ' t I d o n ' t know i t depends on t h e s i t u a t i o n i f t h e y a r e s o r t of p r o l o n g i n g t h e i n e v i t a b l e t h e n I you know I d o n ' t l i k e i t p u t i t t h a t way and I j u s t t h i n k w e l l they're j u s t making t h i s making t h i s l a s t l o n g e r f o r n o t h i n g r e a l l y you know...I j u s t k i n d o f g e t f r u s t r a t e d you know and t h i n k w e l l i t ' s n o t t h e way i t s h o u l d be b u t you know I have t o do i t t y p e o f t h i n g . . . b u t I mean t h e r e a l o t s o f l i t t l e t h i n g s sometimes you d o n ' t a g r e e t o t a l l y b u t you know I j u s t k i n d o f g e t f r u s t r a t e d a b i t and you do them and you might s a y t o somebody e l s e or s o m e t h i n g o r I w i l l t a l k t o t h e o t h e r n u r s e a b i t o r the c h a r g e n u r s e o r s o m e t h i n g b u t you know you s a y s o m e t h i n g t o somebody t h e n you g e t r e a s s u r a n c e t h a t ' s not y o u . Get your f r u s t r a t i o n s o u t I g u e s s . Yeah. One p a r t i c i p a n t d e s c r i b e s o c c u r when w a i t i n g of  brain  the i n c o n s i s t e n c i e s  f o r the p h y s i c i a n s  that  t o make t h e d i a g n o s i s  death.  P. And I'm i n v o l v e d t h e day t h a t t h e y [ p h y s i c i a n s ] make the d e c i s i o n t h a t t h i s p a t i e n t : "Yes he i s b r a i n d e a d . " W h i l e w a i t i n g f o r t h a t d e c i s i o n I f i n d i t more d i f f i c u l t and s o r t o f l i k e i n c o n s i s t e n c i e s t h e r e . R.  Inconsistencies?  P. R i g h t l i k e we're s o r t o f a s s u m i n g t h a t t h i s p a t i e n t i s . . . b r a i n dead and we're c a r r y i n g on e v e r y t h i n g a g g r e s s i v e l y and t h e n t h e y w i l l do t h e s e t e s t s l i k e a p n e i c t e s t s and s t u f f and THEN t h e p a t i e n t i s b r a i n dead um... R. One moment  he i s a l i v e  and t h e n  the next  minute  P. He's n o t . R i g h t and i n t h a t moment w h i l e t h e d e c i s i o n i s being formulated or being determined I f e e l very i m p a t i e n t . L i k e I f e e l l i k e I am t r e a d i n g w a t e r and h u r r y up and w a i t t y p e o f t h i n g . And t h e n I f i n d i t h a r d t o you go w i t h t h e i n o t r o p e s [ i n c r e a s e s h e a r t c o n t r a c t i l i t y ] and go w i t h you l i k e I want t o . . . i f you t h i n k he i s b r a i n dead t h e n ok l e t s s t o p d o i n g t h i s you know and l e t me j u s t comb h i s h a i r and b a t h him and do e v e r y t h i n g t h a t I t h i n k t h a t I p e r c e i v e as c o m f o r t i n g but i t ' s t h a t t r a n s i t i o n p o i n t l i k e j u s t i f I'm  ICU Nurses and the Brain Dead Patient 91  involved when they are making their decision that I find it a bit hard. At other times the participants encounter interpersonal dissonance because the medical decisions are being made by medical residents or interns who lack the knowledge and experience required to care for a brain dead patient. P. Because I felt any chance the organs had of being usable was wrecked and we had inexperience looking after him and you couldn't get them to UNDERSTAND like you could die with those numbers right but it you're trying to save the organs we want good numbers... you keep them as best you could. That was really frustrating. The blood pressure would be through the roof and then in the boot's. It was a brand new bunch, everybody was new and you couldn't get them to...it was just they didn't know what the hell they were doing looking after somebody that was brain dead and the problems that could happen. One participant tells of a situation involving a man with Lou Gehrig's Disease who had been resuscitated twice and was now brain dead.  But she feared that the  inexperience of the intern might result in heroics again being performed if his heart stopped, therefore despite the fact she wanted him to die with dignity she felt she had to do all she could to keep him going. P. He was brain dead. So he wasn't an organ donor. He was not kidney he was nothing. It was just, he was dead brain dead. And I did have a bit of trouble in a sense dealing with that because he hadn't been made a no code. We had been told he was brain dead but there was no clarification of what we are to do in a myocardial arrest and the day nurse hadn't had it clarified. It had been made at sort of shift change and the cardiologist had gone home...I was afraid that if this man coded that our interns, new interns who had been on the unit three or four days were going to start jumping on him because this myocardial hadn't been clarified. THAT'S my concern, my concern was for  ICU Nurses and the Brain Dead Patient 92 the patient that we should start beating up on him again that he couldn't die with a bit of dignity. I mean he had lost his dignity anyway when he tried to die but then when he was trying to die again in the unit I was afraid that and certainly that could happen. His blood pressure dropped and inotropes were started before she [the intern] started the second inotrope I asked that she call the respirologist and get all this clarified...I felt that she should she didn't have the expertise to carry on but she did. She called the respirologist and he fortunately said don't do anything more...So I felt better about that but ah I was afraid he'd...I was doing my best to keep him alive during the night because I was afraid if he did start to die that they would start heroics on him because of this lack of clarification on the no code order. But I was upset purely for him as a chronically i l l person he was obviously dead at this point and was trying to go the whole to do the whole shooting match it appeared to me. The participants also experience dissonance when the physician decides cardiopulmonary resuscitation (CPR) should be performed on a brain dead patient.2 P. We were really annoyed because it was a situation where the lady was BRAIN DEAD but we had a cardiologist who is just sort one of those cardiologists who just isn't very good. I don't know how to say that but anyways that's the problem. And she would not write a no code. She just wouldn't and but she had principal care of the patient. And what do you do? Like the other guys can't override her so the patient coded and unfortunately simultaneously there was a code in CCU, which was a viable code so everybody whipped over there and then we called our code and the CO came up. And we all started talking at once, like all of us around the bed started talking at once: "This lady is brain dead da da da." And the CO looked at us and said: "What the heck are you doing?" And so we explained quickly why we were doing but we were all really unhappy about it. And he just said stop. But it I mean it took the dignity of the lady away. I mean you know ah and I mean our patients have very little left by the time they go through our system, hey. So I mean anytime we can fight to preserve that I mean we do and in this 2. Approximately 10% of all donors experience cardiopulmonary arrest that requires resuscitation during the maintenance phase. (Darby, Stein, Grenvik, Stuart, 1989)  ICU  N u r s e s and t h e B r a i n  Dead  Patient 93  c a s e we d i d n ' t we c o u l d . R. How stop?  get very  d i d you f e e l  far.  at that  We  stopped  point  i t as soon a s  when t h e CO s a i d t o  P. Oh thank g o o d n e s s . E v e r y b o d y was p l e a s e d b e c a u s e i t was s o m e t h i n g t h a t s h o u l d n ' t have been begun i n t h e f i r s t p l a c e , you know. I t ' s j u s t one o f t h o s e bad s i t u a t i o n s t h a t you c a n ' t g e t r e s o l v e d u n t i l s o m e t h i n g happens. One p a r t i c i p a n t i n d i c a t e s about  performing  that  CPR on a b r a i n  dead  she has mixed  feelings  patient.  P. W e l l I - I have mixed f e e l i n g s on t h a t and i f i t ' s gone t h a t f a r I g u e s s I t h i n k j u s t l e t t i n g them go and you know k i n d o f t h e body has made t h e c h o i c e f o r i t . But o f t e n t i m e s I guess i t ' s b e c a u s e we've a l l o w e d t h e e l e c t r o l y t e s to get out of b a l a n c e . You c o u l d s a y i t i s our f a u l t t h a t t h i s i s happening a t t h i s time. Like i n t h e one t i m e . . . t h e c i r c u m s t a n c e I am t h i n k i n g o f i t was b e c a u s e p e o p l e w e r e n ' t aware and on t o p o f t h e s e t h i n g s and so we t e n d t o do t h i n g s t o some p e o p l e i f i t ' s s o m e t h i n g t h a t m e d i c i n e has c a u s e d . We t r y t o r e t r i e v e that f a s t e r . So I have mixed f e e l i n g s . I p e r s o n a l l y i f t h a t ' s t h e way sometimes I t h i n k why n o t j u s t l e t them go and you know t h e y ' v e d i e d k i n d o f t w i c e now. On t h e o t h e r hand t h e n I know l i k e i n t h e one p a t i e n t I t h i n k I was t a l k i n g a b o u t i t was m e d i c i n e ' s f a u l t t h a t um i t h a p p e n e d . I mean d o c t o r s , n u r s e you know l i k e i t was j u s t e v e r y b o d y j u s t wasn't g e t t i n g i t t o g e t h e r on. R. So you f e e l those cases?  more o f an o b l i g a t i o n t o go ahead i n  P. W e l l I have mixed f e e l i n g s a b o u t why t h a t you would want t o do i t . The  lack  of a c o n s i s t e n t  management o f t h e b r a i n dissonance orders. patient  dead  approach patient  that.  i n the medical  and h i s f a m i l y  f o r t h e n u r s e who i s f o l l o w i n g  The p r e v i o u s  account  who was t r e a t e d  regarding  f o r three  I can see  creates  the medical  the b r a i n  days, u n t i l  dead  a change i n  ICU  N u r s e s and t h e B r a i n Dead P a t i e n t 94  medical  directors,  ( s e e page 8 7 ) . apparent  illustrates  this  interpersonal discord  This l a c k of c o n s i s t e n c y i n approach i s a l s o  i n the f o l l o w i n g  statement  of another  participant.  P. I mean we have a t any one t i m e t h r e e t o f i v e r e s i d e n t s and t h r e e d i r e c t o r s t h a t a l t e r n a t e c a l l a week and t h e y a l l have d i f f e r e n t p h i l o s o p h i e s . So I mean i f you have t h r e e d o c t o r s i n t h r e e weeks i n a row you c a n s e e t h r e e d i f f e r e n t a p p r o a c h e s t o i t . And I t h i n k a s a n u r s e i t ' s d i f f i c u l t b e c a u s e you s o r t o f t r y to a l i g n y o u r s e l f w i t h what t h e a p p r o a c h i s t h a t week but I t h i n k i t i s something t h a t n u r s i n g i s going t o struggle with f o r a long time. At t i m e s  the i n c o n s i s t e n c i e s i n medical  due  to disagreements  The  r e s u l t again  beliefs  between d i f f e r e n t  physician  i s personal stress related  c l a s h i n g w i t h events  management i s groups.  to the nurse's  o c c u r r i n g a t the bedside.  P. The h a r d e s t p a r t i s t a k i n g c a r e o f p a t i e n t s where t h e r e i s no d e c i s i o n b e i n g made and t h e y a r e j u s t w a f f l i n g . . . Oh one o f them, t h e l a s t one t h e young f e l l o w I was t a l k i n g a b o u t t h e y t h o u g h t i t was g o i n g t o be a c o r o n e r ' s c a s e . And t h e c o r o n e r was n o t g o i n g t o l e t t h e p a t i e n t g o . . . t o be r e t r i e v a b l e f o r PORT and t h e y were j u s t h o l d i n g b a c k and t h a t was f r u s t r a t i n g b e c a u s e we c o u l d n ' t go ahead w i t h what we w a n t e d t o do to g e t him r e a d y f o r PORT and t h e n we c o u l d n ' t s t o p b e c a u s e we d i d n ' t know i f he was g o i n g t o be a c o r o n e r ' s c a s e o r n o t , i n w h i c h c a s e we'd j u s t send h i m o f f t o t h e morgue, so t h a t t h e y c o u l d have done p a t h o l o g y on h i m [ p a u s e s ] and t h e f i g h t i n g g o i n g on b e t w e e n t h e two d i f f e r e n t t h e p a t h o l o g i s t and t h e o t h e r . . . c o r o n e r and t h e PORT team w h e t h e r t h e y s h o u l d t a k e i t o r w h e t h e r t h e y s h o u l d n ' t o r what t h e l e g a l a s p e c t s o f i t and a l l . t h i s s t u f f . R. D i d t h a t happen a t t h e b e d s i d e ? P. I t d i d some o f i t . R. And d i d i t i n v o l v e you d i r e c t l y o r P. No, j u s t R. B u t b e i n g  indirectly. t h e r e and h e a r i n g i t had an a f f e c t  on you?  ICU  N u r s e s and t h e B r a i n Dead  Patient  95  P4. Yeah ( s o f t l y s p o k e n ) . I t ' s d i f f i c u l t t h a t they were m a i n t a i n i n g t h i s t h i s young man w i t h o u t m a k i n g a d e c i s i o n and j u s t s o r t o f h o l d i n g i t a l l i n t h e a i r and y o u ' r e h o l d i n g h i s w e l l he d o e s n ' t have a l i f e , h e ' s n o t a l i v e anymore b u t j u s t h o l d i n g h i m u n t i l t h e y made a d e c i s i o n and i t was l i k e I w a n t e d t o g e t i t done and o v e r w i t h s o we c o u l d go on w i t h t h e n e x t s t a g e o r t h e next p a t i e n t or whatever. Physician inappropriate the  a c t i o n s which the nurse b e l i e v e s are i n t h e management o f t h e b r a i n dead p a t i e n t o r  p a t i e n t ' s family are another source of i n t e r p e r s o n a l  dissonance. discord  The f o l l o w i n g two a c c o u n t s h i g h l i g h t t h e  b e t w e e n t h e n u r s e and t h e p h y s i c i a n .  P. I t was a r e s i d e n t who was d o i n g a p a p e r and he w a n t e d some numbers f o r h i s s t u d y . And I t o l d h i m t o get l o s t . And i t was a young p a t i e n t who was a head i n j u r y and I t h i n k e v e r y o n e was a l i t t l e a f f e c t e d by t h a t one and i t was v e r y s o r t o f u n s e t t l i n g . A r e a l l y n i c e f a m i l y , v e r y u p s e t and i t was a v e r y s o r t o f e m o t i o n a l b e d s i d e and I t h i n k he had been w i t h us f o r t h i r t y - s i x h o u r s o r s o m e t h i n g l i k e t h a t b e f o r e he had been d e c l a r e d b u t e v e r y o n e knew what t h e outcome was g o i n g t o be. The f a m i l y was r e a s o n a b l y p r e p a r e d f o r i t as much a s t h e y c o u l d be and t h e r e s i d e n t was d o i n g some p a p e r a b o u t some s t u d y . He [ t h e p a t i e n t ] h a p p e n e d t o have a Swan G a n t z i n so he [ t h e r e s i d e n t ] w a n t e d numbers done f r e q u e n t l y , keep t h e s t u d y done e t c e t c and i t was j u s t so seemed s i l l y t o be d o i n g a l l t h a t stuff. And he b a c k e d o f f . He b a c k e d o f f . I t h i n k he c o u l d a p p r e c i a t e a f t e r w a r d s when we s o r t o f d e s c r i b e d t h e s i t u a t i o n a t t h e b e d s i d e t h a t maybe t h i s was n o t t h e most a p p r o p r i a t e p a t i e n t t o be d o i n g t h i s o n .  P. W e l l a s I s a y a c t u a l l y when t h e y a r e d e c l a r e d b r a i n dead you know e v e r y t h i n g i s p r e t t y c u t and d r y . E x c e p t f o r t h i s c a s e I had t h e o t h e r n i g h t and t h e i n t e r n w a n t e d t o do an x - r a y on h i m and I s a i d : "What a r e you g o i n g t o do when you g e t an x - r a y b a c k ? I mean w i l l i t make you f e e l b e t t e r t o s e e t h a t h e ' s . . . t o s e e s o m e t h i n g wrong w i t h h i m . Y o u ' r e g o i n g t o h a v e t o t r e a t i t b u t i f you d o n ' t know what i s wrong w i t h h i m t h e n you d o n ' t have t o . " So maybe I do q u e s t i o n b u t  ICU  N u r s e s and t h e B r a i n Dead P a t i e n t 96  yeah I q u e s t i o n I ' d q u e s t i o n e d a n y t h i n g t h i n k i s you know r i g h t e t h i c a l l y r i g h t r i g h t I would q u e s t i o n i t . The  nurse  and t h e PORT Team.  Some p a r t i c i p a n t s with for  lack  experience  a clashing  t h e a c t i o n s o f members o f t h e P a c i f i c T r a n s p l a n t a t i o n (PORT) Team.  so much t o t h e e t h i c s the  nurses  Organ  The d i s s o n a n c e  p e r c e i v e as an o v e r z e a l o u s n e s s  illustrates  of t h e i r  values  Retrieval r e l a t e s not  o f t r a n s p l a n t a t i o n b u t more t o what  of r e s p e c t f o r the person  following  t h a t I would or m e d i c a l l y  who  o f t h e team and a  t h e donor once was.  the s t r o n g emotions  this  The  dissonance  evokes i n the n u r s e s . P. What I r e a l l y h a t e more t h a n a n y t h i n g and you s e e a c o u p l e o f t i m e s i s b e f o r e t h e p e r s o n i s a c t u a l l y dead [ h i t s t a b l e w i t h f i s t ] t h e y maybe p r e t t y c l o s e t o i t , j u s t have a c o u p l e o f r e f l e x e s t o go b u t t h e y ' r e n o t gone y e t i s um t a l k i n g a b o u t d o n a t i o n o r s e e i n g p e o p l e t h a t a r e on t h e t r a n s p l a n t teams come n o s i n g a r o u n d . L i k e I h a t e t h a t more t h a n a n y t h i n g . . . I l i k e t o have t h a t p e r s o n t o be gone b e f o r e . We c a n t a l k a b o u t i t and s a y i t i s a p o t e n t i a l and t h a t ' s what we a r e w a i t i n g f o r but not to the p o i n t of having the people d e a l i n g w i t h t h e r e c i p i e n t come and have a l o o k . . . I don't l i k e i t b e c a u s e t h e p e r s o n i s n ' t dead y e t . L e t ' s a t l e a s t g i v e him a c h a n c e t o f i n i s h d y i n g b e f o r e we s t a r t t a k i n g o u t h i s b i t s and p i e c e s . . . O n e f e l l o w came up from Emerg and he had numerous t h i n g s . He e x t e n d e d to p a i n a t l e a s t on one s i d e . I t was a few t h i n g s he d i d and a l r e a d y t h e n o t e s were t a l k i n g a b o u t o r g a n donation. Well f i n e . Wait u n t i l he's dead [ h i t s t a b l e t h r e e t i m e s ] and then l e t s d e a l w i t h i t . L i k e p o t e n t i a l o r g a n donor sounds f i n e . They come up and t h e y ' r e b a s i c a l l y b r a i n dead b u t n o t when you c a n e l i c i t a p a i n r e s p o n s e . . . I can a c c e p t the f a c t t h a t i s where we a r e headed and be aware o f t h a t but w h i l e t h e r e i s s t i l l something l e f t of t h a t person then l e t s n o t i n v o l v e t h e r e s t o f t h e team o r w h a t e v e r u n t i l t h e y ' r e g o n e . . . l i k e l e t s w a i t u n t i l he d i e s b e f o r e we s t a r t t a l k i n g a b o u t what p a r t s we c a n use h e r e and who they a r e going to f i t i n h e r e . I j u s t g e t so a n g r y when I s e e someone c r e e p i n g a r o u n d o r s e n d i n g o v e r  ICU  N u r s e s and t h e B r a i n Dead  Patient 97  t h e i r s p i e s I j u s t f e l t l i k e i s b e c a u s e t h e y know t h e y a r e n o t welcome h e r e . . . I t h i n k i t was e x p r e s s e d p r e t t y s t r o n g l y t h e r e t h a t we d i d n ' t l i k e t h e v u l t u r e s c o m i n g a r o u n d u n t i l t h e y were i n v i t e d .  P. I t h i n k . . . i t ' s r e a l l y h a r d t o s a y p r o b a b l y b e c a u s e t h e y ' r e [ t h e b r a i n dead p a t i e n t ] y o u t h . I t , and t h e h o v e r i n g o f t h e team, t h e PORT team o r whomever w a i t i n g f o r them t o d i e . I j u s t don't l i k e t h a t v u l t u r e standing there w a i t i n g . That I f i n d d i f f i c u l t not a c t u a l l y c a r i n g f o r t h e body a s s u c h p r e t t y d i f f i c u l t . We're d o i n g a l l t h e work f o r i t . I n a d d i t i o n , one p a r t i c i p a n t b e l i e v e s presence of the t r a n s p l a n t pressure  on t h e f a m i l y  team p l a c e s  the premature  an u n n e c e s s a r y  members.  P. T h e y ' r e [ t h e t r a n s p l a n t team] n o t s u p p o s e d t o be anywhere i n t h e c o u n t r y u n t i l t h a t p a t i e n t i s d e c l a r e d . I t w o u l d be a c o n f l i c t o f i n t e r e s t . T h e r e have been a few p r o b l e m s i n t h e p a s t where maybe t h e t r a n s p l a n t team i s s c o u t i n g o r w h a t e v e r . Or i f t h e r e i s a p a t i e n t t h a t t h e y h e a r i s n o t d o i n g w e l l . And so we j u s t s a i d b a s i c a l l y t h a t u n t i l we d e c l a r e them f o r them t o b a c k o f f and we w o u l d c a l l them when t h e p a t i e n t was d e c l a r e d . . . W e l l t h e f i r s t few [ b r a i n dead p a t i e n t s ] t h a t were a r o u n d t h e y j u s t seemed t o be i n t h e u n i t . You know c h e c k i n g t h i n g s o u t and s a y i n g : "How's t h i n g s going?" And I t h i n k a f e w p e o p l e were s e n s i t i v e t o t h a t f a c t l i k e y o u know h e r e t h e y a r e s n o o p i n g and t h e p a t i e n t i s n ' t even d e c l a r e d . So um I t h i n k i t i s b e s t f o r them t o s t a y away and t h e y ' r e q u i t e happy t o do t h a t o r a t l e a s t most o f them a r e t h e y have b a c k e d o f f . R. So t h a t  bothered  you i n i t i a l l y ?  P. W e l l y e a h . Yeah i t d i d I f i g u r e d t h e f a m i l y had t o make a d e c i s i o n and I d o n ' t t h i n k t h e y s h o u l d h a v e any p r e s s u r e p u t on them j u s t b e c a u s e somebody was w a i t i n g f o r a h e a r t o r y o u know w h a t e v e r . It's their decision t o make. P e o p l e do n o t want t o d o n a t e a l l t h e t i m e . One  p a r t i c i p a n t f e e l s t h e p u b l i c i z i n g o f t h e need f o r  o r g a n d o n o r s by PORT was r e s p o n s i b l e  for a conflict  where  ICU Nurses and the B r a i n Dead P a t i e n t 98  f a m i l y members were p r e s s u r i n g a mother to donate her daughter's  organs.  P. I used to be r e a l l y gung ho f o r PORT. I'm not as gung ho f o r PORT because PORT pushes too hard. Pushes too hard f o r r e t r i e v a l of organs. And I understand down the road they have a p o s i t i v e v a l u e . . . We've d i s c u s s e d t h i s at length at work because i t . . . a h some people are r e a l l y gung ho. I t doesn't matter. I t doesn't matter how you get the organs as long as you get them so you w i l l b e n e f i t somebody, ok...there i s a l o t of ads f o r PORT hey. And there was at that p a r t i c u l a r time there had been s e v e r a l b i g t h i n g s on BCTV about organ donation and i t was j u s t around that time...I had even seen them on TV and at the time I s a i d : "Whoa l i k e they're r e a l l y pushing too hard." And l i k e you know people get on ideas and they go with them and we had commented on that they were pushing a l i t t l e too hard at that time and probably enough to i n f l u e n c e one or two members of the f a m i l y . And so as a r e s u l t the pressure on t h i s one f a m i l y member was extremely. R.. How d i d you p e r s o n a l l y f e e l at that  time?  P. Oh I was annoyed about that cause you can't contravene a person's r i g h t s with ah s o r t of humanitarian goal down the road of you know look at a l l these people we are going to help, ok. For t h i s p a r t i c i p a n t  the promoting  of t r a n s p l a n t a t i o n  by PORT opposes her o p i n i o n that people should be f r e e to make t h e i r own d e c i s i o n s without any p r e s s u r e . to t h i s p a r t i c u l a r  With regards  case, t h i s nurse a l s o d e s c r i b e s  i n t e r p e r s o n a l dissonance o c c u r r i n g among the n u r s i n g s t a f f (page 1 0 2 ) . Another  participant  f i n d s her p e r s o n a l values are i n  c o n f l i c t with how the t r a n s p l a n t team t r e a t s the b r a i n dead patient.  From her p o s i t i o n the team does not give the  p a t i e n t the r e s p e c t he deserves f o r once having been a living  person.  ICU N u r s e s  and t h e  Brain  Dead  Patient 99  P . And i t ' s sometimes easy to become a l i t t l e b i t p r o t e c t i v e i n a way or a l i t t l e b i t t e r i n a way w i t h the whole p r o c e s s of a n a l y z i n g and e n s u r i n g t h a t they a r e good matches and e v e r y t h i n g e l s e b e c a u s e I t h i n k i t g e t s . . . I use the term v u l t u r i s t i c a l i t t l e b i t . And y o u ' r e l o o k i n g a f t e r t h i s p a t i e n t t h a t ' s i n the bed and y o u ' r e t r y i n g to e n s u r e t h a t t h e i r a i r w a y i s p a t e n t and that t h e i r v i t a l s i g n s are s t a b l e . T h e y ' r e i n a good cardiovascular balance. Oxygen exchange i s g o o d . T h e i r f l u i d s a r e j u s t on and i f t h e y ' r e i n DI y o u ' v e got t h a t matched up and y o u ' v e got t h e i r electrolytes j u s t r i g h t , you know. Hematological status is f i n e . And i t ' s . . . t h e y I f e e l d e f i n i t e l y come i n and t h e y l o o k a t numbers and they l o o k a t l i n e s and t h e y d o n ' t l o o k a t who i s a t t a c h e d a t the end of t h a t w h i c h maybe j u s t v e r y p e r t i n e n t I t h i n k but I t h i n k sometimes i t i s a l i t t l e b i t h a r d when you have been d e a l i n g w i t h t h i s p a t i e n t two or t h r e e d a y s . P e r h a p s i t has been a l o n g e r p r o c e s s f o r the d e v e l o p m e n t of b r a i n d e a t h t h a t a l l of a sudden bang t h a t i s the end of i t and they a r e now a p o t a s s i u m of 3 . 4 . They a r e not M r . J o n e s who has a p o t a s s i u m of 3 . 4 . They a r e the p a t i e n t o v e r t h e r e who has a p o t a s s i u m of 3 . 4 or t h e i r h e m o g l o b i n has d r o p p e d and I f i n d sometimes t h a t i s a l i t t l e b i t d i f f i c u l t to d e a l w i t h . That i t i s i t ' s . . . t h e y all l o o k a t numbers and a l t h o u g h I a l w a y s f e e l l i k e I am c o n t r a d i c t i n g m y s e l f so much when we a r e d i s c u s s i n g t h e s e t h i n g s b e c a u s e I do r e a l i z e the i m p o r t a n c e of t h a t and I mean what i s the p o i n t of s a y i n g poor M r . Jones. Mr J o n e s i s now b r a i n dead so we have to g e t on w i t h the d u t y of the day w h i c h i s to f i n d a match i f t h e y have c o n s e n t e d . Another you  letter  informant i n d i c a t e s  by PORT i s  that  the  sending  of  a thank  offensive.  P . The o t h e r t h i n g PORT g i v e s us i s a l i t t l e letter w h i c h t e l l s w h i c h t h a n k s you f o r l o o k i n g a f t e r . . . t h e f i r s t l e t t e r I got I f o u n d r e a l l y o f f e n s i v e . Well i t was l i k e Dear P . t h a n k s f o r c a r i n g f o r w h a t e v e r . The k i d n e y s were t r a n s p l a n t e d a t . . . , one k i d n e y went h e r e and was p e e i n g x amount of c c s per hour and one k i d n e y went h e r e and t h e h e a r t went h e r e . . . a n d I t h o u g h t GIVE ME A BREAK but I got a l e t t e r j u s t r e c e n t l y from them w h i c h i s s t i l l v e r y s i m i l a r but i t was much more humane. L e s s of a p a r t s d e p a r t m e n t l e t t e r . I'm s t i l l not s u r e how I f e e l a b o u t t h o s e l e t t e r s but t h a t one I found a l o t l e s s o f f e n s i v e t h a n the o r i g i n a l .  ICU  N u r s e s and t h e B r a i n Dead P a t i e n t 100  A l o n g s i m i l a r l i n e s a n o t h e r n u r s e i n d i c a t e s she f o u n d some o f t h e a c t i o n s  o f PORT a s b e i n g  were i n c o n g r u e n t w i t h a person.  c a l l o u s because  they  t h e f a c t t h a t s h e knows t h e p a t i e n t a s  She a l s o i n d i c a t e s a b e l i e f  t h a t PORT p r o b a b l y  does n o t mean t o be c a l l o u s b u t s i m p l y  sees the s i t u a t i o n  from a d i f f e r e n t  perspective.  P. You s e e t h e y [PORT] do s o m e t h i n g I t h i n k i s v e r y c a l l o u s and I d o n ' t t h i n k you know o r t h e y f e e l i t ' s callous. They p r o b a b l y mean i t i n t h e n i c e s t way. E v e r y t i m e t h e y come and g e t a p a t i e n t t h e y b r i n g a bag of c o o k i e s . Now t h e y mean i t i n t h e NICEST WAY b u t you know a bag o f c o o k i e s d o e s n ' t c u t i t . You know what I mean? They w o u l d be b e t t e r j u s t t o come i n and p i c k up, a t l e a s t t h i s i s my own p e r s o n a l o p i n i o n I c a n ' t s p e a k f o r e v e r y b o d y e l s e . They w o u l d do b e t t e r t o come i n and p i c k up t h e p a t i e n t and go o f f t o t h e OR and do t h e i r t h i n g and n o t d r o p o f f a bag o f c h o c o l a t e f i n g e r s o r go a r o u n d and s e e t h a t e v e r y b o d y h a s PORT b u t t o n s , you know...They made a C h r i s t m a s c a r d and p u t o r g a n s on i t you know. I u n d e r s t a n d t h a t t h e y a r e f o r l i f e . I r e a l l y DO. BUT f r o m o u r p e r s p e c t i v e we knew t h e p e r s o n t e c h n i c a l l y a b o u t a s much a s we c a n know a b o u t them and i t j u s t seems c a l l o u s . The  n u r s e and h e r n u r s i n g  To a l e s s e r e x t e n t  the p a r t i c i p a n t s also  i n t e r p e r s o n a l dissonance with these s i t u a t i o n s t h e i r their care  expectations  colleagues.  their  colleagues  with  regard  generally  colleagues.  In  do n o t meet  to the standard  f o r t h e b r a i n dead p a t i e n t .  t h a t when n u r s e s do n o t t a l k  nursing  experience  of nursing  One p a r t i c i p a n t i n d i c a t e s  to the p a t i e n t or t a l k  over the  p a t i e n t she i s t r o u b l e d . P. I t a l k t o them s t i l l e v e n t h o u g h t h e y a r e b r a i n dead, I t h i n k t h a t ' s a way t h a t I d e a l w i t h i t m y s e l f . A l o t o f my c o - w o r k e r s d o n ' t and i t s o r t o f b o t h e r s me a l i t t l e b i t . I - I know t h a t t h e i r f u n c t i o n i s gone b u t I j u s t keep t h i n k i n g t h a t i f t h e y c a n r e m o t e l y h e a r  ICU  N u r s e s and t h e B r a i n  Dead  Patient 101  a n y t h i n g f o r some r e a s o n and we d o n ' t know i t . Then I t h i n k t h a t t h e y would r a t h e r know what was g o i n g on and we a r e g o i n g t o t u r n them o r t h e y ' r e g o i n g t o e x p e r i e n c e a n e e d l e poke i n t h e i r arm o r s o m e t h i n g . Most o f t h e time I w i l l do t h a t .  P. When t h e y t o t a l l y i g n o r e t h e p e r s o n . They t a l k o v e r the p e r s o n : "Do you want t o meet f o r l u n c h n e x t week?" I s t i l l f e e l t h e r e s h o u l d be a s e n s e o f p r o f e s s i o n a l i s m at t h e b e d s i d e even t h o u g h t h i s p a t i e n t i s b r a i n dead and c a n n o t h e a r y o u . Does n o t a c k n o w l e d g e y o u r presence. I t h i n k we s t i l l have t o remember o u r purpose there i n that i t i s not a complete s o c i a l time. In  addition,  the d e p e r s o n a l i z a t i o n  not  t r e a t i n g the p a t i e n t  for  this  with  respect  of the p a t i e n t or  r e s u l t s i n dissonance  same p a r t i c i p a n t .  P. We have had d i f f e r e n t d i s c u s s i o n s a b o u t t h i s t h a t some p e o p l e r e f e r t o i t [ t h e b r a i n dead p a t i e n t ] as h e r e i s t h i s c a s i n g t h a t ' s h o l d i n g t h e o r g a n s and there's nothing else i n there. It's just basically organs that you're l o o k i n g a f t e r . I d o n ' t know i f I go as f a r . J u s t t h i n k i n g t h a t p e r h a p s t h e i r s o u l has l e f t i f t h e r e i s s u c h a t h i n g and o r I s t i l l f e e l l i k e I am nursing a person. I d o n ' t f e e l l i k e I am n u r s i n g two k i d n e y ' s and a h e a r t and l u n g and a p a i r o f c o r n e a s and maybe some l o n g b o n e s . I don't t h i n k i n those terms. R. So i t ' s i m p o r t a n t f o r you t o i d e n t i f y as s t i l l b e i n g a p e r s o n then?  the b r a i n  dead  P. I f i n d i t i s . I um i t ' s one o f my b i g t h i n g s i s when we have a p a t i e n t t h a t has d i e d and t h e y a r e p r e p a r e d t o go d o w n s t a i r s t o t h e morgue I r e a l l y HATE IT when we a r e t r a n s f e r r i n g a p a t i e n t from a bed o n t o the s t r e t c h e r t h a t goes d o w n s t a i r s and whoever i s p u l l i n g t h e head o v e r t h e y l e t t h e head bang down on the t r a n s p o r t b e d . I t ' s s o m e t h i n g t h a t r e a l l y b o t h e r s me and i t ' s n o t b e c a u s e I f e e l t h a t p e r s o n c a n f e e l o r t h a t i t m i g h t h u r t t h e i r head o r a n y t h i n g . It's a l i t t l e b i t o f d i s r e s p e c t i n my view t h a t I s t i l l f e e l t h a t we owe t h a t p e r s o n no m a t t e r who t h e y a r e I d o n ' t c a r e i f t h e y grow up and l i v e on i n t h e a l l e y s somewhere o r w h a t e v e r b u t I f e e l t h a t we s t i l l have t o r e s p e c t t h a t p e r s o n as h a v i n g BEING, a human b e i n g o r  ICU  Nurses and the B r a i n Dead P a t i e n t 102  IS a human being me.  and that kind of thing r e a l l y  bothers  Another p a r t i c i p a n t gives as an example of i n t e r p e r s o n a l dissonance among nursing  colleagues  i n v o l v i n g opposing views towards o b t a i n i n g  a case  organs from b r a i n  dead p a t i e n t s . P. I'm t h i n k i n g i n p a r t i c u l a r we had a young g i r l and I can't remember her age but she was e i t h e r l a t e teens e a r l y twenties. And I think she was a MVA. And she went b r a i n dead. And the f a m i l y or the m a j o r i t y of the f a m i l y wanted her to be an organ donor but her mother didn't. And t h a t ' s her mother's r i g h t , I f e e l . And my f e e l i n g and i t ' s only my personal o p i n i o n but I f e e l that i f there i s one d i s s e n t e r i n the f a m i l y you should leave w e l l enough alone because some people can not t o l e r a t e the thought of t h e i r love one being you know hacked i n t o p i e c e s , r i g h t . Well t h i s mother couldn't r e a l l y not get through her f e e l i n g s but the f a m i l y the pressure s t a r t e d with the f a m i l y and they convinced her and I use "convince" very r e s e r v e d l y , they convinced her to allow t h i s to happen. But i t was r e a l l y c o e r c i o n , you know. And t h a t ' s wrong. That i s r e a l l y wrong because that mother has to l i v e many more years, you know with her memories and i f her memory i s marred by the f a c t that her daughter was cut i n some manner that was not s u i t a b l e to her a b i l i t y to cope with that you've l e f t her i n some kind of a h e l l of a limbo. And I can remember i t caused a l o t of d i s s e n t i o n amongst us. R. Your u n i t  staff?  P. Yeah because there was some of us who s o r t of f e l t l i k e I do, i f mother objected end of s t o r y . And then there was the other end of the continuum that s a i d : "Doesn't matter. S h e ' l l get over i t . " I say who knows and so thank goodness what happened i n the end was a l l of the p a t h o l o g i s t were away on a b i g convention out of the c i t y and they couldn't come back u n t i l Monday or Tuesday and i t was a coroners case so the p a t h o l o g i s t was needed to be there. Ok, so there wasn't one available. So when the f a m i l y , t h i s was l i k e a F r i d a y , when they heard about i t and they were delayed, they would be delayed 36 to 48 hours, they got r e a l l y angry and s a i d f o r g e t it...because they didn't think that the way was a p p r o p r i a t e , which was f a i r . But I thought at  ICU Nurses and the Brain Dead Patient 103  least it took the burden off the mom because she was really pushed hard...So I can remember the conversation after when she was let go and I can remember saying well that was good for the mora cause it sort of took the pressure off and some people were really angry. R. Because? P. The organs were wasted quote unquote. what it takes, that's what it takes.  But if that's  Though this participant feels the mother was being coerced by other family members, she also feels that these same family members were unduly influenced by the publicity surrounding transplantation.  These views are described on  page 98. In addition, she indicates that the split in the family regarding transplantation and the eventual outcome where no organs were removed created dissention amongst the nursing staff.  This interpersonal dissonance is related to the  differing personal values and beliefs of the nurses. Whereas, this nurse is "not as gung ho for PORT" (page 98), one of her nursing colleagues feels that with donation "...you see an end result to taking care of a patient" (page 54).  This colleague (page 54) reveals how emotionally  drained she felt when organs were not retrieved from this young girl. Personal Distress The presence of personal or interpersonal dissonance produces subjective tension which is expressed as a variety of emotions.  Some of the terms the participants used to  ICU  N u r s e s and  the  Brain  Dead  Patient 104  describe  t h e i r f e e l i n g s are  being  very  drained,  being  a n n o y e d , and  experienced  frustrated, feeling  f e e l i n g saddened, being being  anger which  afraid.  One  i s directed  rotten,  "pissed  off",  participant  at  the  brain  dead  patient. P. They were j u s t young and the way they d i e i t ' s u s u a l l y a c c i d e n t a l . . . r i d i n g a m o t o r c y c l e 100 km a hour i n heavy t r a f f i c when you h i t s o m e t h i n g t h a t ' s avoidable. And t h a t makes me a n g r y . . . a n d t h a t makes me want to go out t h e r e and shake them a l l . . . t h e young guys. I t seems l i k e s u c h a w a s t e . The his  experience  family  draining,  difficult,  and  These p e r s o n a l the  amount o f  present.  The  designation in  an  for  discomforts and  as  resolve  The  strategies  dead  patient  gruelling, scary,  interpersonal  the the  following from  the  r e s u l t i n a need  of  and/or  they  will  perspective  of  family  from  i s a prominent  distancing  o c c u r s and  the  patient  feature how  of  or the  care  are  review the  these  participants.  i n some i n s t a n c e s  the  transcriptions.  Why  i t occurs w i l l  be  is  the  t h e i r nursing  dissonance sections  reduce  d i s s o n a n c e which  distancing target  to  Distancing Distancing  and  just horrible.  another  experiencing.  brain  i n terms s u c h as  p a r t i c i p a n t s use  to  the  p h y s i c a l l y demanding, g h a s t l y ,  personal  of  attempt  coping  caring  i s described  emotionally hard,  of  addressed.  ICU  N u r s e s and t h e B r a i n  Dead  Patient 105  Rationale The  f o r distancing.  p a r t i c i p a n t s indicate that  from the p a t i e n t taking  f o r three  t h e i r work home w i t h  reasons. them.  they d i s t a n c e The f i r s t  themselves emotionally.  highlight 1.  each o f these three  Protection  o f home  i s to avoid  The s e c o n d i s t o c o n t i n u e  t o work i n t h e i n t e n s i v e c a r e u n i t and t h e t h i r d protect  themselves  The f o l l o w i n g  i s to excerpts  rationales for distancing.  life:  R. I s i t i m p o r t a n t t o d e t a c h y o u r s e l f situation?  from the  P. To a c e r t a i n e x t e n t b e c a u s e y o u do s e e a l o t o f i t and i t i s n ' t j u s t t h e b r a i n dead p a t i e n t s . . . i t ' s a l l k i n d s o f s i t u a t i o n s and i f y o u g e t t o o i n v o l v e d w i t h i t you c a n ' t go h o m e . . . c a r r y on a l i f e a t home i f y o u ' r e e x p e n d i n g y o u r s e l f a t work.  P. Y e s b e c a u s e I d o n ' t l i k e t a k i n g my work home w i t h me...But a s I s a i d most o f t h e t i m e I t u r n m y s e l f r i g h t o f f f r o m i t and j u s t d e a l w i t h what I have t o and go home and t o t a l l y f o r g e t a b o u t i t .  2.  To c o n t i n u e t o f u n c t i o n  i n the i n t e n s i v e care u n i t :  P. B u t t h e n y o u c a n ' t r e a l l y d w e l l on them [ t h e b r a i n dead p a t i e n t s ] b e c a u s e t h e n y o u w i l l y o u won't be a b l e t o do y o u r work f i n e y o u know. So ray s o r t o f t h o u g h t i s w e l l i t h a p p e n e d I c a n ' t do a n y t h i n g a b o u t i t . A l l I c a n do now i s make i t e a s i e r f o r t h e f a m i l y o r whoever i s l e f t b e h i n d .  P. I t h i n k w i t h a b r a i n dead p a t i e n t y o u s o r t o f have to s w i t c h your f e e l i n g s o f f f o r both cases whether t h e y ' r e g o i n g t o be a d o n o r o r n o t . . . I d o n ' t t h i n k t h a t I g i v e any more o f m y s e l f e m o t i o n a l l y I t h i n k i t j u s t g e t s me i n t o a c t i o n where I have t o t a k e c a r e o f t h i s p a t i e n t so t h e y c a n t a k e o r g a n s .  ICU N u r s e s and the  Brain  Dead  Patient 106  P . When I f i r s t s t a r t e d i n t h e r e I used to l i k e to go f o r the f u l l s e t [ o f c a r i n g f o r t h e b r a i n dead p e r s o n ] . I d o n ' t any more b e c a u s e I s o r t of come to the wisdom t h a t i t i s too h a r d on y o u , the p e r s o n [ b r a i n dead p a t i e n t ] f o r f o u r days of d o i n g t h a t . I t ' s very t i r i n g b e c a u s e you i n v e s t a c e r t a i n amount o f e n e r g y i n t o t h i s you know and i f you want to l a s t a t i t you have to disengage. You have to be a b l e to s t e p back and g a i n p e r s p e c t i v e c a u s e you have to remember t h a t i t i s n o t your p a i n . I t i s t h e i r [ t h e f a m i l y ' s ] p a i n and y o u ' r e h e l p i n g them work t h r o u g h t h e i r p a i n and you c a n ' t t a k e t h e i r p a i n on and i f you t a k e t h e i r p a i n on y o u ' r e not h e l p i n g them. I t h i n k when I was f i r s t i n t h e r e I d i d n ' t u n d e r s t a n d the d i f f e r e n c e . And maybe I was m e e t i n g my own needs t h e n I d o n ' t know I h a v e n ' t figured that out. A l l I know i s t h a t I'm b e t t e r a t what I do i f I j u s t do i t f o r a s h o r t p e r i o d o f time w h i c h i s f o r us i s two days and t h e n d i s e n g a g e because i f you get too i n v o l v e d y o u ' r e of no v a l u e .  3.  P r o t e c t i o n of  one's  self:  P . I t r y to d e t a c h m y s e l f from the s i t u a t i o n so to speak to a c e r t a i n e x t e n t w h i c h i s my c o p i n g mechanism w i t h w o r k i n g w i t h t h e s e p e o p l e [ t h e b r a i n dead p a t i e n t ]  P . You go home and y o u ' r e a b l e to s h u t i t o f f w h i c h I t h i n k you have t o be a b l e t o . . . y o u have to be a b l e t o t o t a l l y s h u t o f f what happens h e r e . . . j u s t f o r y o u r s e l f f o r y o u r p e r s o n a l you know e m o t i o n s . . . You have to s t e p back and you d o n ' t become i n v o l v e d . You d o n ' t become i n v o l v e d on an e m o t i o n a l l e v e l and I t h i n k t h e r e p r o b a b l y i s a p a r t of us i n a l l of us t h a t keep ourselves s l i g h t l y detached. And i t ' s s a f e s t . It r e a l l y does. I d o n ' t t h i n k we c o u l d l a s t l o n g a t a l l i f we became so e m o t i o n a l l y i n v o l v e d w i t h e v e r y p a t i e n t and e v e r y f a m i l y . I j u s t don't think that happens. How p a r t i c i p a n t s d e s c r i b e  the  The p a r t i c i p a n t s d i s t a n c e  t h e m s e l v e s by  depersonalization  of  the  patient  process  of  or d e t a c h i n g  distancing. either themselves  ICU  N u r s e s and t h e B r a i n Dead  Patient 107  emotionally  from the p a t i e n t .  The n e x t two a c c o u n t s a r e  examples of the d e p e r s o n a l i z a t i o n  that  occurs.  P. I t ' s j u s t a r e c e p t a c l e l y i n g t h e r e . A c o n t a i n e r . . . I've a l r e a d y d i s t a n c e d myself a t t h a t t h a t t h e y become an o r g a n d o n o r . So i t ' s j u s t an a c a d e m i c mass t h a t ' s g o i n g t o t h e OR t h e n .  point  P. I j u s t most o f t h e t i m e I c l o s e m y s e l f o f f f r o m it...From the i t being a person. I think i t ' s a nothing. I t ' s j u s t a b o d y . . . i t ' s n o t f u n c t i o n i n g we're d o i n g a l l t h e work f o r i t . . . N o I d o n ' t t h i n k o f i t as anything. E x c e p t f o r s o m e t h i n g t h a t I am m a i n t a i n i n g ah s o m e t h i n g l i k e a b o a r d o r w h a t e v e r . Other p a r t i c i p a n t s detach themselves e m o t i o n a l l y b e c o m i n g more c l i n i c a l  and by r e c o g n i z i n g  done has been done and t h a t n o t h i n g  a l l that  by  c a n be  more c a n be d o n e .  P. I p u t my e m o t i o n s a s i d e I know t h a t . . . I t h i n k t h a t i s t h e o n l y way t h a t you do d e a l w i t h i t i s p u t t i n g your emotions a s i d e to a l a r g e p a r t . Like looking at i t more c l i n i c a l l y t h a n e m o t i o n a l l y .  P. I t r y t o a c e r t a i n e x t e n t um d e t a c h m y s e l f t o a p o i n t where I want t o be s u p p o r t i v e f o r t h e f a m i l y b u t t h e r e i s a f i n e l i n e o f p e r h a p s o f g e t t i n g i n v o l v e d and s t a y i n g on t h e o t h e r s i d e w i t h o u t b u r s t i n g i n t o t e a r s a t t h e b e d s i d e w h i c h you f e e l l i k e d o i n g f r e q u e n t l y . Saving t h a t time f o r y o u r s e l f i n the bathroom or i n the c h a n g i n g room w i t h o u t a p p e a r i n g t o be c o l d t o t h e f a m i l y b e c a u s e t h a t m i g h t be y o u r c o p i n g mechanism and t h a t ' s t h e way t h a t you d e t a c h y o u r s e l f . I detach m y s e l f w i t h t h i n k i n g t h a t we have done e v e r y t h i n g we can and I g e t v e r y b a s i c a b o u t t h e w h o l e t h i n g and t h a t t h e r e i s n o t h i n g e l s e t h a t we c a n do. I f t h e p a t i e n t i s a p o t e n t i a l d o n o r we a r e g o i n g t o be h e l p i n g someone e l s e and t h a t ' s t h a t . If is  everything  just waiting  distancing  i s done f o r t h e b r a i n dead p a t i e n t and he  t o go t o t h e OR  i s easy.  In fact  then the process of  some o f t h e p a r t i c i p a n t s  ICU  Nurses  and t h e B r a i n  Dead  Patient  108  indicate the  i f anything  they  have  difficulties  i d e n t i f y i n g with  patient. P. I f I come o n s h i f t a n d I'm g e t t i n g a p a t i e n t r e a d y f o r t h e OR a n d I h a v e n e v e r s e e n h e r b e f o r e . . . y o u f e e l v e r y d i s t a n t and i t i s a l m o s t l i k e t h a t p e r s o n i s n ' t even r e a l . You d o n ' t t h i n k o f them a s b e i n g a l i v e anymore. Y o u d o n ' t h a v e t o do y o u r r o u t i n e assessment. Y o u d o n ' t h a v e t o y o u d o n ' t h a v e t o do a l l s o r t s o f t h i n g s t h a t y o u w o u l d w i t h a p a t i e n t who i s a l i v e . A n d o f t e n times the f a m i l y has s a i d t h e i r f i n a l good-byes and y o u n e v e r s e e them a n y w a y s . . . a n d I f i n d i t h a r d t o f e e l anything f o r that person. W h e r e y o u h a v e n ' t met t h e f a m i l y a n d y o u w a l k i n a n d y o u know y o u r p a t i e n t i s i m m i n e n t l y g o i n g t o be g o i n g t o t h e OR t h a t night...I mean i n some s e n s e s i n some w a y s i t ' s e a s i e r [ t h e c a r e of t h e b r a i n dead p a t i e n t ] b e c a u s e you don't have t o e x p l a i n anything to the p a t i e n t . You don't have t o prepare him f o r a n y t h i n g . You don't have t o s e d a t e him t o k e e p h i m on t h e v e n t i l a t o r . You d o n ' t have t o . You c a n do a l l y o u r t h i n g s a n d r u n a r o u n d a n d t h a t patient d o e s n ' t need a n y t h i n g o f y o u .  P. B e c a u s e s o m e t i m e s y o u c a n come o n a n d h a v e a b r a i n dead w i t h e v e r y t h i n g done. The time o f d e a t h i s t h e r e . The f a m i l y h a s been i n and s a i d good-bye and y o u d o n ' t see the f a m i l y a g a i n . So y o u ' r e j u s t l o o k i n g a f t e r t h e body and t h a t ' s l i k e t h a t ' s t h e f i r s t t h i n g I want t o know b e c a u s e I w a n t t o know I g u e s s how much e m o t i o n a l trauma i t ' s g o i n g t o be. Because i f e v e r y t h i n g i s done and t a k e n c a r e o f and t h e f a m i l y h a s s a i d g o o d - b y e i t ' s r e a l l y e a s y t o go t o t h e b e d s i d e a n d a n d do a l l t h e t h i n g s y o u h a v e t o do u n t i l t h e p a t i e n t g o e s t o t h e OR. But then i f you've g o t t h e f a m i l y t o d e a l w i t h then you do s h a r e i n t h e i r g r i e f a n d i t ' s a s h a r e d t h i n g m o r e s o m e t h i n g t h a t . . . I f e e l t h a t I'm f e e l i n g i t b e c a u s e I j u s t i m a g i n e s o r t o f w h a t i t w o u l d be l i k e f o r m e . . . B u t i f everything y o u know t h e f a m i l y h a s s a i d g o o d - b y e a n d t h e y ' v e a c c e p t e d t h e t i m e o f d e a t h a s 9 o ' c l o c k a n d he i s j u s t w a i t i n g t o go t o t h e OR t h e n y e a h i t ' s e a s y y o u don't have t o t a l k t o t h e p a t i e n t . Y o u j u s t do t h e stuff. Four members  participants  makes  indicate  distancing  easier.  that  the absence  of  family  ICU  N u r s e s and t h e B r a i n  Dead  Patient 109  P. I t h i n k b e c a u s e o f my d e v e l o p m e n t o f t r y i n g t o become a l i t t l e more d i s t a n t t o t h e s i t u a t i o n . I find i t i s e a s i e r to a c h i e v e t h a t i f they're [ t h e f a m i l y ] not a t t h e b e d s i d e . T h e y ' r e v e r y u p s e t u s u a l l y and t h e y a r e c r y i n g and t h e y ' r e v e r y e m o t i o n a l . And you t r y and be s u p p o r t i v e a s much as you c a n and sometimes when t h e y a r e n o t t h e r e i t g i v e s you a l i t t l e b i t o f a b r e a k as w e l l from b e i n g a s u p p o r t i v e p e r s o n and i t a l l o w s you t o k i n d o f r e l a x a b i t and g e t your j o b done.  P. I t ' s e a s i e r when t h e y [ t h e b r a i n dead p a t i e n t ] come f r o m a d i s t a n t p a r t o f t h e p r o v i n c e o r w h a t e v e r and t h e f a m i l y d o e s n ' t come down and t h e y a l r e a d y know t h a t he i s b r a i n dead and t h a t t h e y have c o n s e n t e d o r t h e y h a v e n ' t t o w h a t e v e r and t h e y d o n ' t come. It's easier d e a l i n g w i t h t h a t p e r s o n b e c a u s e you d o n ' t know t h e background. You d o n ' t know t h e f a m i l y . You d o n ' t know a n y t h i n g a b o u t them e x c e p t f o r what happened d u r i n g t h e a c c i d e n t o r how t h e y g o t t h a t way.  P. And sometimes I f i n d t h a t once t h e f a m i l y l e a v e s and has s a i d t h e i r good-byes I f i n d i t a l m o s t h a r d t o r e l a t e t o t h a t p a t i e n t anymore b e c a u s e t h e t i e i s gone. Cause t h e f a m i l y i s g o n e . . . I g u e s s t h a t ' s t h e o t h e r s t r a n g e t h i n g t o o i s t h a t you know t h e f a m i l y ' s gone and t h a t t a k e s away t h a t much more from t h i s body there.  P. Maybe h e ' s a J o h n Doe o f w h a t e v e r t h a t t h e r e a r e no f a m i l y members so you d o n ' t g e t t o know a n y t h i n g a b o u t that person of course. Y o u ' r e n o t g o i n g t o t r e a t them any d i f f e r e n t b u t I d o n ' t know I t h i n k you a r e more d e t a c h e d b e c a u s e t h i s i s j u s t a p e r s o n t h a t you d o n ' t know a n y t h i n g a b o u t . Your c a r e i s n ' t d i f f e r e n t b e c a u s e your c a r e i s your c a r e . But I t h i n k i t makes a difference. On t h e o t h e r distancing the  hand  impossible  patient.  This  the presence as the nurse  i s evident  of the f a m i l y can r e a d i l y  i n the f o l l o w i n g  may  make  identify  with  two a c c o u n t s .  ICU  Nurses  and  the  Brain  Dead  Patient  110  P. B e c a u s e I d i d g e t t o know t h e f a m i l y a little b i t . . . k n e w w h a t he was l i k e b e f o r e the a c c i d e n t and s t u f f a n d r e a l i z e d he was a p e r s o n , not j u s t a body lying there. L i k e a c a d a v e r or w h a t e v e r you want t o c a l l i t that's being functioned through the m a c h i n e r y . . . I t ' s i t ' s not easy d e a l i n g w i t h b r a i n dead p e o p l e a n d I f i n d i t l i k e I s a i d m o r e d i f f i c u l t when t h e r e i s f a m i l y a r o u n d b e c a u s e they [ t h e b r a i n dead p a t i e n t s ] came f r o m s o m e w h e r e e l s e a n d they're not t h e r e by t h e m s e l v e s . T h e r e i s somebody e l s e to d e a l with besides the dead p e r s o n . . . I t ' s not l i k e h a v i n g some bum t h a t they p i c k e d o f f the r o a d somewhere t h a t doesn't have a f a m i l y . Doesn't have a s o c i a l b a c k g r o u n d t h a t y o u ' r e g o i n g t o be a w a r e o f . Those are e a s y t o d e a l w i t h when y o u d o n ' t know t h e background. T h e m o r e y o u know t h e h a r d e r i t i s . Or t h e m o r e I know.  P. I t ' s r e a l l y h a r d t o d e a l w i t h f a m i l i e s i n a n y situation. I f i n d i t h a r d t o d e a l w i t h them b e c a u s e l i k e I guess i t gives l i f e to the p a t i e n t . You get to know t h e m a l i t t l e b i t b e t t e r t h r o u g h t h e i r family. You see t h a t t h i s p a t i e n t i s a very v i t a l p a r t i n somebody e l s e ' s l i f e . And I t h i n k i t i s so h a r d t o d e a l w i t h b e c a u s e i t ' s s o much e a s i e r t o g e t emotionally i n v o l v e d when y o u g e t t o know t h e family w e l l a n d maybe t h a t ' s why I f i n d i t a l o t more d i f f i c u l t when y o u a r e t a k i n g c a r e o f a p a t i e n t . . . i t i s s o much e a s i e r t o d e a l w i t h when y o u d o n ' t know t h e m a s a person. At the  times  distancing  must  occur  between  the  nurse  and  family. P. I h a d h a d h i m f o r t h e t h r e e p r e v i o u s s h i f t s and I came on n i g h t s a n d h i s f a m i l y h a d s a i d g o o d - b y e a n d I know t h a t I f e l t r e l i e v e d t h a t I w a s n ' t g o i n g t o h a v e to see them. C a u s e i t was a l m o s t l i k e I had done what I c o u l d f o r them and I had t a k e n them t h r o u g h t h i s p e r i o d w h e r e he b e c a m e b r a i n d e a d b u t I d i d n ' t really want t o see them a g a i n . B e c a m e we h a d s o r t o f s a i d our good-byes. And t h e f a c t t h a t he was d e a d now i n my e y e s i t was e a s i e r t h a t the f a m i l y wasn't there.  ICU  Nurses  and t h e B r a i n  Dead  Patient  111  When  distancing  Distancing involvement the  moment  occurs given  when  may  with they  occur  a t any time  the patient. are assigned  brain  f o r organ  occurs.  death  during  F o r some  i t i s present  to the patient.  has been  the nurse's  declared  from  For others i t  o r when  consent i s  donation.  P. I t h i n k t h e o n l y t i m e t h a t my f e e l i n g c h a n g e i s a f t e r they're d e c l a r e d b r a i n dead and I t h i n k t h a t i t ' s a t t h a t t i m e t h a t I am t r y i n g t o p u l l b a c k a l i t t l e .  P. M a y b e t h e r e i s a p a r t o f me t h a t s h u t s o f f . You know I j u s t k i n d o f r e m o v e m y s e l f . T h e r e i s no s e n s e i n g e t t i n g w o r k e d up a b o u t t h i s . Y o u know l i k e y o u j u s t a c c e p t i t a n d I mean n o t a g r e e w i t h i t . . . S o I g u e s s f o r me I j u s t s o r t o f t r y a n d f l o w w i t h i t . I'm n o t g o i n g t o be a b l e t o do a n y t h i n g a b o u t i t a n d maybe t h e r e i s a p a r t o f me t h a t k i n d o f s h u t s o f f a n d I w i l l do w h a t I h a v e t o t o t a k e c a r e o f t h a t p a t i e n t until they go. B u t I g u e s s my h e a r t a n d s o u l i s n ' t i n t o i t . . . I c e r t a i n l y c l o s e o f f my e m o t i o n s t o w a r d s t h a t person. I t h i n k there i s a d i s a s s o c i a t i o n t h a t you h a v e t o make. And I w o u l d s a y t h a t i s e x a c t l y i t . I go t h r o u g h t h e m o t i o n s o f t a k i n g c a r e o f t h e p a t i e n t b u t I'm c e r t a i n l y n o t i n t o i t .  P. T h e r e i s a d e f i n i t e s w i t c h . . . i t ' s l i k e you're switching t o a n o t h e r g e a r and i t ' s a l m o s t l i k e an academic thing then. I t ' s not i t ' s not I don't t r e a t them l i k e a p e r s o n t h e n s o much. I t ' s more l i k e a textbook type t h i n g . I keep t h e e l e c t r o l y t e s r i g h t . K e e p t h e NUMBERS r i g h t . . . b u t I c a n I know t h a t I s w i t c h i n t o t h a t g e a r a n d s a y : "Ok now t h i s i s t e x t b o o k . This i s academic. T h e n u m b e r s h a v e g o t t o be r i g h t . I can't l e t the blood pressure go b e l o w s u c h a n d s u c h . I've g o t t o k e e p up w i t h t h e o u t p u t a n d a h t r y n o t t o u s e a n y meds o r w h a t e v e r a n d k e e p t h i s b o d y i n p r i m e c o n d i t i o n . . . you s o r t o f t r a i n b o t h your e n e r g i e s and y o u r t h o u g h t t h a t . . . i t ' s s t r i c t l y an a c a d e m i c exercise at that point. And a s f a r a s p e r s o n h o o d o r p e r s o n I think very I don't think along t h o s e l i n e s when I am t a k i n g care of a donor p a t i e n t . L i k e w h e r e a s i f he i s  ICU  Nurses  and t h e B r a i n  Dead  Patient  112  not a d o n o r . p a t i e n t t h e n I am m o r e a w a r e o f t h e p a t i e n t b e i n g . . . t h e b o d y h a v i n g o n c e h e l d a p a t i e n t y o u know l i k e a l i f e a n d t h e r e f o r e I t r e a t t h e m maybe m o r e respectfully. R.  I f they're  n o t an o r g a n  donor?  P. Y E A H . . . when t h e y ' r e a n o r g a n d o n o r i t ' s b e c o m e a n a c a d e m i c e x e r c i s e and you s o r t o f j u s t s w i t c h over t o t h a t mode. Designating In  Another  most  instances  care  i s the patient  when  the assigned  personal then  as the T a r g e t  the r e c i p i e n t  t o whom  patient  or i n t e r p e r s o n a l  designate  either  recipient  or even  providing  care  of Nursing  or target  the nurse  i s brain level  may  the p a t i e n t ' s  Care of  nursing  i s assigned.  dead  then  However  dissonance  occur.  The n u r s e  family,  the  h e r own  self  as t h e r e a s o n  to a b r a i n  dead  patient.  on a  may  transplant  f o r her  Family. Many of  of the p a r t i c i p a n t s  the brain  dead  patient  i s really  family  i s the fulcrum  family  becomes t h e r a t i o n a l e  to  t h e dead The  is  indicate  around  which  that  care  the nursing  care  of the family.  The  nursing  revolves  f o r the p r o v i s i o n  and t h e  of basic  care  patient.  following  the target  accounts  of nursing  provide  evidence  that  the  family  care.  P. He [ t h e b r a i n d e a d p a t i e n t ] d o e s n ' t know. He c a n ' t perceive anything. He i s l i k e b r a i n d e a d y o u know. So y o u j u s t do i t f o r t h e p e o p l e t h a t c a n f e e l t h a t t i m e and most o f them t h e f a m i l y I g u e s s . . . Y e a h I t h i n k more when y o u ' r e n u r s i n g a p a t i e n t , a b r a i n d e a d p a t i e n t , y o u ' r e r e a l l y n u r s i n g m o r e I t h i n k maybe t h e f a m i l y then the p a t i e n t . Except the p a t i e n t u s u a l l y the care i s n o t v e r y h a r d on y o u . You're not doing a l o tof  ICU  Nurses  and  the  Brain  Dead  Patient  113  busy with  things with the family.  the  patient  so  you're  mainly  dealing  P. I f i n d a l s o t h a t y o u a r e by no m e a n s n o t only n u r s i n g t h a t p a t i e n t but you a r e n u r s i n g t h e family p r o b a b l y more t h a n the p a t i e n t i n a l o t o f c a s e s d e p e n d i n g on how they are c o p i n g w i t h the situation.  P. J u s t p r e p a r i n g the f a m i l y j u s t p r e p a r i n g the family for the d e a t h . B a s i c a l l y the n u r s i n g i s j u s t basic n u r s i n g c a r e y o u know t u r n s o r k e e p t h e p a t i e n t clean and c o m f o r t a b l e . The m a i n p a r t t h e n i s t h e g r i e v i n g f a m i l y . . . I mean i t ' s v e r y s a d b u t I'm not r e a l l y I s u p p o s e my c o n c e r n when t h e p a t i e n t i s a t t h a t stage t h e y d o n ' t know. I'm more c o n c e r n p r o b a b l y a b o u t o u t s i d e t h i n g s l i k e the f a m i l y w a i t i n g i n the waiting room c a u s e t h a t ' s a l o t t o u g h e r to d e a l w i t h t h e n a d e a d b o d y who's n o t here.  P. T h e o t h e r t h i n g i s f o r r e l a t i v e s t h a t I c a n ' t do anything r e a l l y f o r the p a t i e n t anymore but i f they see t h e i r l o v e d one w i t h t h e i r h a i r a l l n i c e l o o k i n g , i n a c o m f o r t a b l e p o s i t i o n a n d y o u know c l e a n a n d w h a t n o t then I've done s o m e t h i n g f o r them. R. So c a r i n g f o r t h e for their family? P. T h a t ' s s o r t o f you f e e l t h a t you t h a t ' s a l l you've The the  following  patient  is  dead  a l l you've s t i l l want got left.  five for  brain  accounts  the  benefit  patient  is  also  caring  got l e f t sometimes l i k e t o do s o m e t h i n g m o r e . And  indicate of  the  that  care  provided  family.  P. B e c a u s e w h a t I f o u n d i s I ' l l g u s s y t h e m a l l u p . O f t e n shampoo t h e i r h a i r , f r e s h bed, p u t some a f t e r s h a v e on i f i t ' s a g u y , a n t i p e r s p i r a n t w i t h some s m e l l i n i t , w h a t e v e r and t h a t s e e m s t o make t h e f a m i l y feel better. I mean i t d o e s n ' t h e l p y o u know i n t h e overall scheme of t h i n g s . But the f a m i l y seems t o f e e l better b e c a u s e I t h i n k t h e y t h i n k we c a r e o r we wouldn't bother.  ICU  N u r s e s and t h e B r a i n  Dead  Patient 114  P. I t ' s w e i g h i n g t h e s i t u a t i o n . I f the f a m i l y i s very c o n c e r n e d a b o u t them [ t h e b r a i n dead p a t i e n t ] b e i n g c o m f o r t a b l e a t a l l times then perhaps f o r the f a m i l y I might t u r n t h e p a t i e n t b u t I would l i k e t o make t h a t p a t i e n t as c o m f o r t a b l e as p o s s i b l e . . . I would comb t h e i r h a i r b e c a u s e i f t h e f a m i l y came i n I'm s u r e t h a t t h e y would want them t o l o o k c l e a n .  P. But I g u e s s I t h i n k t o o o f t h e f a m i l y t h a t ' s coming in. I f t h e f a m i l y i s s t i l l coming i n l o o k i n g a t t h a t p a t i e n t I g u e s s I t r y and t h i n k how t h e y would f e e l too. How I would f e e l i f I was i n t h a t s i t u a t i o n and t h a t means a l o t t o p e o p l e t h e y d o n ' t u n d e r s t a n d a l l the m e d i c a l a s p e c t b u t t h e y s u r e know i f t h e i r l o v e one looks n i c e .  P. Q u i t e o f t e n I d o n ' t t h i n k t h e y r e a l l y r e a l i z e t h e e x t e n t o f what y o u ' r e d o i n g and t o me sometimes they j u s t need t o t a l k . Yeah so you i f t a l k w h i l e y o u ' r e d o i n g t h i n g s you know u s u a l l y t h e y f e e l b e t t e r i f y o u ' r e dong mouth c a r e o r w h a t e v e r and t h e y t h i n k y o u ' r e t a k i n g c a r e o f t h e p a t i e n t and making them c o m f o r t a b l e even i f t h e y a r e b r a i n dead. I think i t makes them f e e l b e t t e r i n t h a t j u s t b e c a u s e t h e y ' r e b r a i n dead t h e r e i s n o t h i n g you c a n do f o r them and j u s t d o n ' t shove them i n t o a c o r n e r .  P. A g a i n i t ' s a b i t o f a f r u s t r a t i o n t h i n g [ d o i n g c o m f o r t measures on a b r a i n dead p a t i e n t ] and o f t e n i n t h o s e t i m e s we do i t f o r t h e f a m i l y so t h e p a t i e n t l o o k s good o r t h a t t h e y f e e l t h a t we a r e s t i l l t r e a t i n g t h e m . . . I t [ n u r s i n g c a r e ] d o e s n ' t make any d i f f e r e n c e t o the p a t i e n t . I t may make some d i f f e r e n c e t o t h e family. T h e y ' r e h a v i n g a h a r d time d e a l i n g w i t h i t and i t sometimes makes a d i f f e r e n c e t o you i n t h a t you a r e d o i n g a l i t t l e b i t o f s o m e t h i n g even though you c a n ' t see a p o i n t . By able  refocusing  to reduce  nursing  dissonance  care  on t h e f a m i l y  and t o d e r i v e  the nurse i s  personal  benefits.  ICU  N u r s e s and t h e B r a i n  Dead  Patient 115  P. I t h i n k maybe i f I c a n i n any way make t h e s i t u a t i o n a l i t t l e l e s s p a i n f u l f o r f a m i l i e s . . . I t h i n k so many p e o p l e have so many t e r r i b l e e x p e r i e n c e s i n h o s p i t a l s and t h a t ' s s o m e t h i n g t h a t t h e y a s s o c i a t e w i t h a b s o l u t e l y u n t i l t h e day t h e y d i e . I f we c a n i n anyway make e a s e t h e p a i n a t a l l t h e n I would hope t h a t ' s what we c o u l d do o r p e r h a p s what I c o u l d d o . . . i f t h e y remember not- n e c e s s a r y you know t h e y d o n ' t r e a l l y have t o remember t h a t t h e n u r s e P. or a n y t h i n g b u t j u s t t h a t : " T h e r e was t h i s one n u r s e or t h e r e was t h i s group o f n u r s e s and t h e y j u s t e x p l a i n e d e v e r y t h i n g so t h o r o u g h l y so t h a t we know what was h a p p e n i n g and we knew t h a t t h e r e was a b s o l u t e l y n o t h i n g e l s e t h a t c o u l d be done" and t h a t t h e y f e l t v e r y i n f o r m e d and i f t h a t c o u l d a t a l l h e l p them t h e n i t ' s a l l w o r t h i t . . . I think s i n c e you and I have been d i s c u s s i n g t h i s my main f o c u s has a l w a y s been t h e f a m i l i e s and i t r e a l l y i s t h e main f o c u s f o r me.  P. I t ' s [ n o t i f y i n g r e l a t i v e s when b r a i n dead p a t i e n t goes t o t h e o p e r a t i n g room] s t r i c t l y f o r them. Like i t ' s s o m e t h i n g I'm a b l e t o do f o r t h e r e l a t i v e s and i t h e l p s me. I t i s s o m e t h i n g p o s i t i v e t h a t I c a n do f o r t h e . . . b e c a u s e I am d o i n g i t f o r them you know l i k e b e c a u s e I t h i n k i t h e l p s them..."Ok now i t r e a l l y i s . He r e a l l y i s gone now." R. So f o r you h e l p i n g t h e f a m i l y i s a p o s i t i v e o f c a r i n g f o r t h e b r a i n dead p a t i e n t ?  aspect  P. Y e s . Yes b e c a u s e w i t h t h e b r a i n dead p a t i e n t t h a t ' s not an o r g a n d o n o r . . . l i k e I s a y t h a t i s a l l I ' v e g o t l e f t a l m o s t . . . i f you c a n g i v e s o m e t h i n g p o s i t i v e t o a r e l a t i v e t h e n yeah i t does i t does d i r e c t l y h e l p you too.  P. I f i n d t h e t h i n g t h a t make my j o b e a s i e r i s i f . . . I l i k e t o d e a l w i t h t h e f a m i l i e s and i f I c a n somehow make them r e a l i z e t h a t t h e i r l o v e one i s h e r e and t h e reason that t h i s i s happening i s because of these f a c t o r s t h a t have o c c u r r e d and t h a t they a r e i n n o t h i n g , no d i s c o m f o r t - s t r e s s i n g t h a t p o i n t seems t o h e l p t h e f a m i l y a l o t . I f e e l I f e e l b e t t e r i f I know the f a m i l y i s d e a l i n g w i t h t h e s i t u a t i o n r e a s o n a b l y w e l l quote unquote. And by r e a s o n a b l y w e l l I mean n o t r o a m i n g a r o u n d on t h e f l o o r i n g r i e f b u t t h e y ' r e t r y i n g to u n d e r s t a n d t h e s i t u a t i o n and g r a s p o n t o i t . I f I  ICU  N u r s e s and t h e B r a i n  Dead  Patient 116  can make them f e e l a l i t t l e b e t t e r t h a t was t h e n I f e e l better. I f I f e e l that they're t o t a l l y d i s t r a u g h t I've been a b s o l u t e l y c o m p l e t e l y i n e f f e c t u a l i n my n u r s i n g c a r e o f them t h e n I f e e l l i k e I h a v e n ' t done a good job. The p a t i e n t may be w e l l l o o k e d a f t e r , t h e p a t i e n t i s w e l l looked a f t e r but i f I can't help the f a m i l y to some e x t e n t t h e n I f e e l l i k e I h a v e n ' t done my c o m p l e t e job.  P. But a t t h e same time when you g e t t o know t h e f a m i l y and i n a way i t ' s r e a l l y sad and i t ' s r e a l l y t r a g i c b u t you u s u a l l y meet t h e . . . f a m i l y r e a l l y opens up t o you and you and you g e t t o meet p e o p l e and g e t t o know them and t h a t some how t a k e s away l i t t l e b i t about how sad it i s . R. So knowing  the f a m i l y  P. I f i n d knowing t h e f a m i l y h e l p s you g e t t h r o u g h i t b e c a u s e you a r e m e e t i n g y o u ' r e m e e t i n g p e o p l e t h e y ' r e at an i n c r e d i b l y a w f u l p o i n t i n t h e i r l i v e s and how y o u ' r e a b l e t o h e l p them t h r o u g h i t . At l e a s t t h a t ' s how I f o u n d i t ' s been and I w i l l r e q u e s t t o l o o k a f t e r them f o r t h e whole s t r e t c h . R. And b e c a u s e  of being  able  to help  the f a m i l y ?  P. B e i n g a b l e t o h e l p them and you know t h e y r e a c h o u t so d e s p e r a t e l y f o r s o m e t h i n g when t h e y a r e g o i n g through t h i s . You know I know a l o t o f p e o p l e t h e most d i f f i c u l t t h i n g i s when you come on and t h e p a t i e n t d i e s t h a t i s d e c l a r e d b r a i n dead and you h a v e n ' t met the f a m i l y y e t . I t ' s a l w a y s e a s i e r when you know them and you have been a b l e t o e s t a b l i s h a r a p p o r t .  P. W e l l I l i k e b e i n g a b l e t o h e l p t h e f a m i l y come t o terms w i t h i t . L i k e I g e t some s a t i s f a c t i o n from t h a t i f I c a n s h a r e i t w i t h them o r h e l p a l i t t l e b i t even though i t h u r t s . . . I l i k e d e a l i n g w i t h t h e f a m i l i e s o f the b r a i n dead i n a way. I f I c a n f e e l l i k e I am h e l p i n g them a t a l l come t o terms w i t h i t . Or j u s t g i v i n g them a l i t t l e b i t o f s u p p o r t w h i c h sometimes you can s e e t h a t t h a t h e l p s me...If you have d e v e l o p e d a r e a l l y good r a p p o r t w i t h t h e f a m i l y t h a t you would want to s t a y f o r t h e i r sake as w e l l as y o u r s b e c a u s e you g e t something out of i t t o o .  ICU  N u r s e s and  the  Brain  Dead  Patient 117  R.  What i s t h a t  that  you  get  out  of i t ?  P. I g u e s s you g e t a f e e l i n g o f b e i n g u s e f u l or of d o i n g some good of a s i t u a t i o n t h a t t h e r e i s v e r y l i t t l e from t h e i r p o i n t of v i e w , v e r y l i t t l e good t h a t comes out o f i t . They can t a l k to you and t h e y meet you, t h e y know you a l i t t l e b i t . So you j u s t f e e l l i k e you a r e d o i n g some good f o r them, some s o r t o f s u p p o r t . Therefore, dissonance helping  for  i s resolved  the  family  Transplant By  this  are  stress  they  able  whether  whether  or  the  not  goal  of  achieved.  to  their  care  reduce  encounter  patient. This  depends on  others  recipient.  refocusing  nurses  is  p a r t i c i p a n t , and  on  their  the  recipient  dissonance  when c a r i n g  i s evidenced  organ  i n the  for  the  and  the  brain  following  the  personal  dead  account.  P. I n i t i a l l y I f e l t a l o t more f r u s t r a t i o n b e c a u s e I d i d n ' t t h i n k of the t h i r d p e r s o n . And t h i n k i n g of the t h i r d i s s o r t of one way I have of c o p i n g w i t h l o o k i n g a f t e r somebody t h a t i s b r a i n dead and p u t t i n g a l o t of e f f o r t i n t o s o m e t h i n g t h a t you f e e l i s a waste of e n e r g y you know to some e x t e n t . R. So by t h i n k i n g a b o u t f e e l l i k e you're... P. of  designation  focus  of  nursing  participant's or  give  third  person  As q u i t e as f r u s t r a t e d t h a t t h e r e a p u r p o s e to what I am d o i n g .  The the  the  life  nursing to an  congruent with  of  the  care  establishes  This  goal  their  philosophies  of  don't  more  recipient  a goal  which  i n d i v i d u a l makes t h e i r  you  seems to be  unknown t r a n s p l a n t  also  care.  now  i s to  nursing  for  as  the  benefit care  nursing.  P. W e l l i f t h e y become an o r g a n donor t h e n t h a t ' s good for the r e c i p i e n t b e c a u s e t h e r e a r e so many p e o p l e out there that require organs. That's a b e n e f i t .  ICU  N u r s e s and  the  Brain  Dead  Patient 118  R. Does t h a t make i t e a s i e r b r a i n dead p a t i e n t ?  f o r you  P. W e l l Right.  a goal  i t makes i t more of  to  care  to work  for  the  towards.  P. B e c a u s e someone e l s e w i l l r e c e i v e t h o s e o r g a n s you want them to be i n the b e s t shape t h e y can be so you r e a l l y t r y h a r d t o keep the b l o o d p r e s s u r e p e r f e c t l y n o r m a l , the u r i n e o u t p u t r i g h t where you want i t you know. I t ' s not a f u t i l e e f f o r t to do t h a t b e c a u s e the b e t t e r you can keep the o r g a n s the b e t t e r the c h a n c e the r e c i p i e n t h a s .  P. I t h i n k i t ' s um o r g a n d o n a t i o n i s becoming b i g g e r and b i g g e r and I t h i n k t h a t i n terms of t h a t you have to do X amount of c a r e i f you a r e g o i n g to r e a p the b e n e f i t s i n the end. And i n my mind t h a t i s e t h i c a l l y r i g h t . I f you a r e g o i n g to be h e l p i n g a l i v i n g p e r s o n f u l f i l l t h e i r l i f e b e t t e r t h e n t h a t i s i s r i g h t now to me t h a t i s e t h i c a l l y r i g h t . Having  a goal  to work t o w a r d s h e l p s  rewards f o r h e r s e l f . f  Two  the  p a r t i c i p a n t s give  nurse  to  evidence  obtain to  this  act. P. And w i t h the one t h a t i s an o r g a n donor t h e r e i s a c e r t a i n r e w a r d w h i c h you g e t a c e r t a i n p o s i t i v e t h i n g w i t h k e e p i n g t h i s a c a d e m i c s i t u a t i o n a t i t ' s p r i m e and you can k i n d of g a i n some some s a t i s f a c t i o n f r o m t h a t and know i n the l o n g r u n t h a t i t w i l l you know b e n e f i t somebody.  P. I f the p a t i e n t ' s g o i n g f o r m u l t i p l e o r g a n d o n a t i o n t h e n I f e e l w e l l maybe we have done a good JOB w i t h t h i s p a r t i c u l a r PATIENT b e c a u s e you know numerous p e o p l e who a r e g o i n g to b e n e f i t from t h i s . T h a t ' s when we, I t h i n k , f e e l a l i t t l e b i t b e t t e r .  ICU  Nurses  and t h e B r a i n  Dead  Patient  119  Nurse. A they are  few o f t h e p a r t i c i p a n t s  are providing really  makes  them  difference The  nursing feel  care  to the brain  the nurse.  better  even  to the p a t i e n t  accounts  of f i v e  indicate  Doing  though  that  dead  participants  patient  things  i t makes  i n the o v e r a l l provide  at times that  when they  f o r the patient little  scheme  of  evidence  things. for this  point. P. T h i s p a t i e n t i s a d e a d p a t i e n t a n d why a r e we d o i n g this? S o m e t i m e s I t h i n k i t i s j u s t f o r o u r own s e l v e s .  P. I mean y o u a r e m o r e i n t e r e s t e d i n now i f y o u ' r e g o i n g t o t r y and keep o r g a n s t h a t ' s what you f o c u s i s n o t t h e c o m f o r t m e a s u r e s a s much. So y o u r focus changes a l i t t l e b i t there. I mean y o u g o t t o do m o u t h care. I t m a k e s me f e e l b e t t e r b u t t h a t d o e s n ' t c h a n g e anything. I t m a k e s me f e e l b e t t e r a n d I l i k e t h e f a m i l y t o t h i n k t h a t they have a l i t t l e b i t o f d i g n i t y as w e l l .  P. I mean a s f a r a s b a s i c n u r s i n g c a r e r e a l l y m a t t e r a t t h a t p o i n t w h e t h e r we o r b u t i t m a k e s me f e e l b e t t e r u s u a l l y  i t doesn't turn the patient when i t ' s d o n e .  P. I g u e s s I a l w a y s do t o my p a t i e n t s y o u know o r I s o m e t i m e s I c a l l t h e m I d o n ' t know l i k e a f u n n y name l i k e ' s w e e t i e ' . . . I d o n ' t know maybe i t ' s j u s t t o y o u because you're d e a l i n g with that p a t i e n t i t ' s s o r t l i k e h e ' s my p a t i e n t y o u know a n d I'm v e r y when I l o o k after p a t i e n t s I'm v e r y I d o n ' t know w h a t ' s t h e w o r d b u t um l i k e maybe p o s s e s s i v e l i k e t h i s i s my p a t i e n t . This i s my a r e a a n d I a l w a y s l i k e y o u know t o k e e p my a r e a t h e way I w a n t i t a n d my p a t i e n t l o o k i n g j u s t how I w a n t h i m a n d maybe j u s t f o r me I know he c a n ' t h e a r . He can't f e e l anything. B u t i t m a k e s me f e e l b e t t e r I guess.  ICU  N u r s e s and t h e B r a i n Dead  Patient 120  P. And p e r h a p s when I'm s p e a k i n g t o them [ t h e b r a i n dead p a t i e n t ] when we're d o i n g t h a t I'm n u r s i n g m y s e l f not t h e p a t i e n t . For care  one p a r t i c i p a n t  helps  her to remain  providing  the p a t i e n t with  basic  human.  P. I do mouth c a r e , eye c a r e . I t u r n them. I t a l k to them. I t a l k t o them when t h e y ' r e DEAD when I'm g e t t i n g them r e a d y t o f o r t h e morgue. I still call them Tom, D i c k o r what e v e r t h a t ' s j u s t my p e r s o n a l philosophy. R. To t a l k t o P. The dead p e r s o n . You know I f i g u r e t h e day I s t o p d o i n g t h a t I have t o g e t o u t t h a t day b e c a u s e t h a t s o r t of makes me human I t h i n k . One p a r t i c i p a n t always p o s s i b l e . emotionally  i n d i c a t e s that nursing  For instance, with  and p h y s i c a l l y  to take  there  i s more time so you " c a n g i v e either  of the nurse  your  an o r g a n  donor  b u s y " and t h e time  there  emotional,  care  very  the nurse  but with  i s not  "you're i s not  a non o r g a n  donor  your a t t e n t i o n to the  own o r t h e r e l a t i v e s " Summary  The  essential  a b r a i n dead coexisting and  s t r u c t u r e of the experience  p a t i e n t i s dissonance  beliefs,  perceptions,  a c t i o n s w i t h i n one's s e l f  between one's s e l f Personal  dissonance  philosophy activities,  about  and a n o t h e r occurs  nursing,  to the concept  which  values,  (personal  of c a r i n g f o r  i s the c l a s h i n g of opinions, dissonance)  knowledge or  (interpersonal dissonance).  in relation  t o the n u r s e ' s  to t r a d i t i o n a l  nursing  of b r a i n death,  care  to organ  ICU  N u r s e s and t h e B r a i n  Dead  Patient 121  retrieval  and t r a n s p l a n t a t i o n ,  responsibilities Interpersonal families,  and t o p r o f e s s i o n a l  and t h e n u r s e ' s  dissonance  physicians,  occurs  own e m o t i o n a l between  needs.  t h e n u r s e and  t h e PORT Team and h e r own  nursing  colleagues. Both which  forms of d i s s o n a n c e  the p a r t i c i p a n t s d e s c r i b e  frustration, The to  "pissed  presence of t h i s reduce  distancing target  of nursing  depersonalization When d e s i g n a t i n g patient  no l o n g e r  Instead, recipient  subjective  and/or care.  o r even  providing  tension  The f o r m e r  a third  person  i s the reason family,  the nurse  care.  and b e i n g  results  by  p e r s o n as t h e  involve  or emotional as the t a r g e t f o r nursing  t h e unknown  herself  in efforts  utilizing  a third  may  afraid.  dissonance.  i s accomplished  of the p a t i e n t  the p a t i e n t ' s  rotten  designating  distress  terms s u c h as  and i n t e r p e r s o n a l  reduction  tactics  i n personal  using  off", feeling  the p e r s o n a l  Dissonance  for  result  detachment. of care, the  activities. transplant  becomes t h e r a t i o n a l e  ICU  N u r s e s and  the  Brain  Dead  Patient 122  CHAPTER 5: In  this  chapter  which r e p r e s e n t providing  care  relation  to  findings  will  the  the  follow  will  addressed.  person  The this  of  i s based  dissonance.  dead  personal  target  consonant  exists other  (1957) u s e s  the  the  and  internal On  the  dissonance  are:  mores,  one  participants'  1957).  (1)  one  cognition  accounts  relation  between  being and  (4)  past  i n d i c a t e that  belief  one's is,  one  them i s the  follow  s i t u a t i o n s w h i c h may  included  of  relationship  would  inconsistency,  and  pair  or  that  exists within  cognition  Four  for  cognitive  about  'fit',  (2)  from  the  lead  to  culture  i n a more  experience. these  a  reviewed.  conceived  or  hand a d i s s o n a n t  logical  cognition,  the  of  terms c o n s o n a n c e  one's s e l f ,  consistency  other  be  knowledge, o p i n i o n ,  cognitions  then  obverse of  (Festinger,  encompassing  about  p a i r of  other  dissonance  r e l a t i o n s h i p between any any  the  in  designation  of  of in  of  developed  will  as  Festinger  i f the  (3)  care  theory  I f the  individual.  nursing  Festinger's  be  presented  discussion  the  on  which  from  of  and  dissonance  environment,  be  study  experience  interpersonal  personal  cognitions  follows  and  Dissonance  could  the  The  Personal  the  behaviour.  of  framework w h i c h was  to d e s c r i b e  the  research  will  literature.  dissonance  about  FINDINGS  the  patient  Then d i s t a n c i n g  the  concept  study  the  First,  as  of  essential structure  pertinent  Four.  third  findings  to a b r a i n  Chapter be  the  DISCUSSION OF  four  The situations  ICU  N u r s e s and  the  Brain  Dead  Patient 123  are  applicable  provision the  of  care  following  inconsistency treated  as  to  two  the  discord  to a b r a i n accounts  i s seen  i f he  is  to  which i s seen w i t h dead  patient.  indicate  occur  that  when the  For  the instance,  logical brain  dead  is  alive.  P. Cause sometimes you t h i n k t h a t morgue i n s t e a d of b e i n g c a r e d f o r  t h e y s h o u l d be i n the way t h e y a r e .  the  P. They a r e s t i l l dead no m a t t e r how you l o o k a t whether you a r e g o i n g to be a donor or whether t h e y ' r e not. And i f you a l l o w y o u r s e l f to t h i n k a b o u t t h a t i t ' s k i n d o f c r e e p y to t h i n k t h a t you a r e t a k i n g c a r e of t h i s dead p a t i e n t . . . The  accounts  dissonance outlined  also  for  the  of  a number of  r e s u l t s as brain  participants  'culture  indicate  mores' a r e  not  that  clearly  dead.  P. The p a t i e n t would be b r a i n dead when you come on and you c o u l d a s k : "Do you do a n y t h i n g ? " I mean t h e y ' r e b r a i n dead, t h e y d o n ' t know what y o u ' r e d o i n g or what y o u ' r e not d o i n g .  P. And I a l s o d o n ' t know how to donor or the p o t e n t i a l donor or Festinger's contained  within  relation  to  they are  unable  what n u r s i n g patient. believe  the  third  s i t u a t i o n of  dissonance  the  to r e c o n c i l e  i s with  the  nursing  being  cognition  i s seen  in  p a r t i c i p a n t s e x p e r i e n c e when  their  provision  involves  person...the dead p e r s o n .  a cognition  a more e n c o m p a s s i n g  A l l p a r t i c i p a n t s , with that  t r e a t the the b r a i n  personal of  the  caring  care  philosophy to  a brain  exception for l i v i n g  of  of dead  one,  individuals.  ICU  N u r s e s and t h e B r a i n Dead P a t i e n t 124  Consequently, provide  care  Finally,  inconsistencies to the b r a i n  the p r o v i s i o n  i s often incongruent  nursing  experiences.  situations  of care with  to the b r a i n  involving  they  sending  dead  the p a r t i c i p a n t ' s  The f o l l o w i n g a c c o u n t s  past  illustrate  this  a p a t i e n t to the o p e r a t i n g  room, d i s c o n t i n u i n g t h e v e n t i l a t o r treatment  when as n u r s e s  dead.  patient  in  exist  and t h e c o n t i n u a t i o n o f  f o r a dead p a t i e n t .  P. I t h o u g h t i t was k i n d o f a g r o s s t h i n g c a u s e you send a c r o s s a warm p e r s o n and n o t h i n g comes back e x c e p t an empty b e d . And t h a t i s n o t a n o r m a l n u r s i n g t h i n g . The n o r m a l n u r s i n g t h i n g i s you send somebody t o t h e OR and you g e t somebody back. I t j u s t s o r t o f goes w i t h i t , right?  P. But t h e r e i s j u s t s o m e t h i n g t h a t i s i n c o n g r u e n t a b o u t b e i n g a n u r s e and t u r n i n g a v e n t i l a t o r o f f , I t h i n k . . . I t a l m o s t . . . f e e l s a b i t u n r e a l b e c a u s e i t i s so c o n t r a r y t o what we do.  P. T h e r e i s some f r u s t r a t i o n sometime and you've s o r t of f a i l and y e t y o u ' r e s t i l l c o n t i n u i n g o n . You've r e a l l y f a i l e d t o save t h e i r l i v e s and y e t y o u ' r e still c o n t i n u i n g on t o c a r e f o r them.  P. L i k e I ' v e done a l l I c a n do and now t h e y ' r e g o n e . . . I guess I j u s t t h i n k t h e i r l i f e i s o v e r . They s h o u l d be taken o f f [ t h e v e n t i l a t o r ] immediately. When t h e y ' r e c o n s i d e r e d b r a i n dead t h e y ' r e dead. Take them o f f and l e t them be. T h e i r l i f e i s f i n i s h e d you know. And t h a t ' s hard i f t h e y ' r e n o t . Furthermore, of  F e s t i n g e r proposes  p s y c h o l o g i c a l d i s c o m f o r t which  physiological  drive  dissonance  i s analogous  i s a state to the  s t a t e s o f hunger and t h i r s t .  Therefore,  ICU Nurses and the Brain Dead Patient 125 crucial to his theory is that "dissonance, that is, the existence of nonfitting relations among cognitions, is a motivating factor in its own right" (Festinger, 1957, p. 3). Accordingly, when the participants of this study experience internal discord they are motivated to reduce the personal distress which is present. Festinger's theory has generated much research and controversy which has yet to be resolved.  Cooper (1971)  proposes that "a person will experience cognitive dissonance only to the extent that he feels responsible for his discrepant behavior" (p. 354) and if undesired and irrevocable consequences result (Copper & Goethals, 1974; Copper & Worchel, 1970; Goethals & Cooper, 1972). The individual's acceptance of this responsibility and recognition of the undesirability of the unalterable outcome then results in "dissonance motivation, that is, aversive pressure to change one's attitude" (Cooper & Fazio, 1984, p. 257).  However, there is also the view that dissonance  results from a discrepancy between self-concept and the outcome of behaviour (Aronson, 1969; Greenwald & Ronis, 1978; Nei, Helmreich & Aronson, 1969; Muldary, 1983). "Thus, individuals strive for consistency for the purpose of maintaining an orderly and predictable sense of self and preventing variations from disrupting their lives" (Muldary, 1983, p. 81) rather than for maintaining consistency among their cognitions.  At the center of this controversy is the  ICU Nurses and the Brain Dead Patient 126 question of cognitive dissonance as a motivational state or simply as a state of inconsistency which is then dependent on self-concept or responsibility and type of outcome to determine motivation to change a behaviour or cognition. Elkin and Leippe (1986) contend that research to date has not answered this theoretical question or resolved the practical issue of "how people typically deal with cognitive inconsistency, driven or not" (p.64).  The findings of this  research study contribute to the pragmatic issue of dissonance in relation to how intensive care unit nurses deal with internal and external discord resulting from the provision of care to brain dead patients. The application of cognitive dissonance theory to nursing appears to be relatively uncommon with only one article having been retrieved from a computer search of the literature.  Lederach and Lederach (1987) report on a six  year study to assess cognitive dissonance in nursing students with a strong religious background enrolled in a psychiatric/mental health nursing course at a Mennonite college.  For this purpose the authors had previously  developed the Religious and Mental Health Inventory (RMHI) which is a five point Likert scale.  However, the  development of the RMHI and the resulting six year study occurred only after a number of observations were made by one of the authors.  These observations indicated that  dissonance did occur between the students' religious beliefs  ICU  N u r s e s and  the  Brain  Dead  Patient 127  and  their perception  of  the  p r i n c i p l e s of  mental  health  may  be  related  taught. In  addition,  attribution their  there of  illness  perception  symptom  of  than helped Lederach, In  a more f o r m a l  religion  p.  analysis  or  dissonance  structure  of  caring  Despite literature providing reasons from  many of  of  the  i s also  brain  occurrence  work o f  dead as  the  education  of  of  the  rather  (Lederach  &  on  and  i n the  the  the  nursing  experience a number  can  be  dying.  His  thesis  influenced  i s that  framework of  which  As  well,  participants  (1981) comes the  nurses.  education  the  literature.  death are  the  of  of  extracted  suggestion  i s i n e v i t a b l e when c a r i n g  between  cognitive  essential  i n the  d e a t h and which  that  in-depth  patient.  dissonance  to  professional's  of  patient,  reactions  incompatibility  of  to  t h r o u g h an  concludes  dead  dead  Sinacore  internal conflict  or  difficult  information  internal conflicts  the  be  sometimes h u r t  part  dissonance  have been n o t e d  From  their  a psychiatric  hospitalized  interviews  for a brain  the  as  t h i s researcher  existing literature  describe  that  the  are  s c a r c i t y of  to  outcomes to God  also has  to  32).  cognitive  care  for  the  the  on  who  fashion  comparative personal  I t may  clients  1987,  and/or  religiosity  in clients.  acknowledge t h a t  dissonance  stresses  by  there the  for  the  the  generic  is a health  science  and  basic  ICU  N u r s e s and t h e B r a i n Dead  Patient 128  technology  and d e a t h  experiential, concepts  reconcile  and d y i n g  education.  antinomies  p. 1 2 3 ) .  reflects  personal.  " i s affectual, As a r e s u l t ,  c a n n o t be  of h e a l t h  At b e s t , t h e l e a r n e r  i s l e f t to  i n a p e r s o n a l t u g o f war" ( S i n a c o r e ,  One o f t h e p a r t i c i p a n t s  upon t h i s  humanistic  effectively  w i t h i n the g e n e r a l a r c h i t e c t u r e  professions  1981,  and h i g h l y  of death  integrated  e d u c a t i o n which  of t h i s  study  also  point:  P. . . . t h e y [ t h e p a t i e n t ] a r e s t i l l dead a f t e r a l l and t h a t ' s v e r y d i f f i c u l t , e s p e c i a l l y when we're used t o t a k i n g c a r e o f t h e l i v i n g . . . i t j u s t goes a g a i n s t what we're s o r t o f t a u g h t . . . t h e y [ n u r s i n g s c h o o l s ] don't t e l l you about t h a t . That's f o r sure. I t doesn't fall i n t o a neat l i t t l e c a t e g o r y . I t ' s a very d i f f i c u l t area that's f o r sure. Others  (Bunch & Z a h r a ,  Thomas, B. 1986) a l s o and  effective  dying role which life  patient  assert  behaviours  and d e a t h .  behaviours  and t h e l i v i n g .  with  that  nurses  for their  death  &  lack preparation involvement  with the  does n o t p o s s e s t h e utilize  those  and w h i c h a r e a s s o c i a t e d w i t h  will  the p a t i e n t  1966; R e i s e t t e r  she w i l l  As i l l u s t r a t e d  the behaviours  knowledge  that  I f the nurse  to d e a l w i t h  she i s f a m i l i a r  accounts  will  role  1976; Q u i n t ,  i n the p a r t i c i p a n t s '  be i n o p p o s i t i o n t o t h e  i s dead and p e r s o n a l  dissonance  exist. A number  participants philosophy a brain  of the accounts have d i f f i c u l t y  indicate  reconciling  o f what n u r s i n g i s w i t h  dead  patient.  Quint  that  many o f t h e  their  personal  the p r o v i s i o n  (1967) a r g u e s  that  of care to not o n l y  ICU  Nurses  and  the B r a i n  Dead  Patient 129  are  the primary  with  the death  placed  o c c u p a t i o n a l g o a l s of n u r s i n g t h r e a t e n e d o f the p a t i e n t  conflicting  work the n u r s e reactions She during  to  p r e s s u r e s which  i s expected.to  including  that  and  the pronouncement  through minute  n o t h i n g more can  caring  f o r the b r a i n  of events  t o b e i n g dead status  this  the h o s p i t a l becoming  an  setting organ  may  donor  close  f o r the n u r s e  by  with  the p a t i e n t ' s  be  the  body and  internal  this  patient  jumps from  (Walker,  any  final  i s not discord  watch  To  is a  further  of death  the  one  change i n  There  nursing  There  go  being a l i v e  1985).  due  For  normal  apparent  b r i n g s the death  no  the  does n o t  the s t a t e  the n o r m a l  not o c c u r .  events  ( Q u i n t , 1967).  patient  prolonged  and  Therefore, closure  the f o l l o w i n g  of d y i n g ,  dissonance occurs.  (1967) s t a t e s do  of  done, the d e a t h  The  dissonant s i t u a t i o n ,  Quint  chart.  be  the n e x t w i t h o u t  or treatment  which  of  there i s  her p e r s o n a l  sequencing  dead  i s absent.  i n e x p e c t a t i o n s and  confound  and  of death  the p r o c e s s of d y i n g but  clinical shift  perform  the d e f i n i n g  recognition  sequencing  the n u r s e  are a s s o c i a t e d  d e s c r i b e s the n o r m a l  d y i n g as  the nurse  on  death.  also  finally  but  within  patient activities  of a p a t i e n t  to a  i s no p r e p a r a t i o n  notation possible  i n the and  as  patient's evidenced  occurs:  P. When t h e y [ t h e b r a i n dead p a t i e n t ] a c t u a l l y t a k e o f f f o r the OR I have ... t h i s ... e m p t i n e s s . P r o b a b l y because I'm n o t g o i n g to f i n i s h the j o b . . .  ICU N u r s e s and t h e B r a i n  Dead  Patient 130  As d i s c u s s e d describe  a number  responsible  i n Chapter  Two,  of f a c t o r s which they  f o r making  the p r o v i s i o n  brain  dead p a t i e n t  which  r e l a t e to the d i f f i c u l t y  accepting  difficult.  the f a c t  questioning conflicts  Youngner  that  believe are  of n u r s i n g  findings  care  of t h i s  to a study  some p a r t i c i p a n t s have i n  the p a t i e n t  of the reason  regarding  The  e t a l . (1985)  i s brain  for nursing  transplantation  care,  confirm  dead, t h e and t h e  personal  Youngner's  statements. Sophie's  e t a l . (1983) s t u d y  number o f ICU n u r s e s diagnosis present  of b r a i n  study  accepting  physical  findings  (1989) i n d i c a t e physicians) lack is  two  study. question  Pallis  death...must d e a t h means.  conceptual  study  the  a f i n d i n g of  this  death  difficulty  without  by Youngner  58% o f h i s r e s p o n d e n t s  clarity  concept  regarding  i n the a c c o u n t s  be d e f i n e d  be r e l a t e d  be l o g i c a l l y  (195 n u r s e s of d e a t h .  d e a t h and  and  death  that  brain  and  This death  carry  derived  concept  o u t and from  and p h i l o s o p h i c a l p r e m i s e s "  is a  the  of  o f what  the d e c i s i o n s explicit  (p.124).  this  conceptual  the " c r i t e r i a  t o some o v e r a l l  t e s t s we  et a l .  o f some p a r t i c i p a n t s o f  (1988) i n d i c a t e s t h a t  The  small  proof.  that  w h i c h must  a  regarding  indicating  of b r a i n  do n o t have a c o h e r e n t  evident  make s h o u l d  i s also  of t h e n u r s e s  of a r e c e n t  of c o n c e p t u a l  also  This  the pronouncement  additional The  ( 6 % ) have r e s e r v a t i o n s  death.  with  i n d i c a t e s that  Others  we  ICU N u r s e s and  the B r a i n  Dead  Patient 131  (Cowles,  1984,  G r e e n & W i k l e r , 1980; W i k l e r  1989) have c o n c u r r e d  that  between  of b r a i n  of  the c r i t e r i a  death  health  cognitive  without  a clear  death  &.Weisbard,  relationship  and t h e g l o b a l  incoherence w i l l  c o n t i n u e to e x i s t  (1985) n o t e s  that  "while tests  are c o n t i n u a l l y  been done  to e x p l a i n  why  the death  of the b r a i n  necessary  and s u f f i c i e n t  condition  f o r the death  being"  (preface).  between former  death  He a l s o  around  is a o f a human  o f a human b e i n g and d e a t h  of a person.  of s c i e n t i f i c  to have d i e d  fact  their  whereas  the  on a number o f l e v e l s ;  m o r a l l y or s p i r i t u a l l y "  participants this  work has  relationship  psychologically, two  very l i t t l e  d i s c u s s e s the  being a matter  be s a i d  improving  f o r the d e a t h o f  the b r a i n  For  among  care personal.  Lamb  "may  concept  cognitive  (Lamb,  The latter  physically, 1985,  p. 7 ) .  dissonance i s centered  relationship.  P. I f the p e r s o n i s [ h a s ] a c t u a l l y d i e d t h e n t h a t ' s . . . w e l l now I'm g e t t i n g h e r e two t h i n g s . Cause I b e l i e v e the p e r s o n i s a c t u a l l y gone, dead. But t h e body i s s t i l l a l i v e !  P. B r a i n dead and p h y s i c a l l y d e a d . . . B r a i n dead i s t h e d e a t h o f an organ...Ok t h a t ' s t h e s o u l b u t d e a t h i t s e l f i s . . . w h e n t h e r e ' s a c o m p l e t e body d e a t h . The c o n f l i c t s concept their  of b r a i n  the p a r t i c i p a n t s  death  may  also  be r e l a t e d  work e x p e r i e n c e they have seen  determined.  describe  r e g a r d i n g the  t o how  the death  In some c a s e s , t h e p h y s i c i a n  during  of a  patient  a s s e s s e s f o r the  ICU  N u r s e s and  the  Brain  Dead  Patient 132  absence  of  cardiac  and  respiratory function  instances  the  cessation  of  brain  function.  I t may  two  types  of  death.  Lamb  a c t u a l l y contains  three  actually  literature  emphasis  formulations  of  two  types  death with  and  neurological)  that but of  death that  of  this  vital  third and  of  the  that  that  cessation inform[s]  is]...death  i s not  cardio-respiratory death"  (Lamb,  clarity  concept. two  1985,  regarding  on  The sets  brain  or  be  cardiac that  death  of  p.29).  d i s s o n a n c e which nurses  distinct  of  but  and  the  death.  that  The  related there  second  are  of  asserts  the  person  e i t h e r by  the  for brain  death.  only  the  (traditional  concept  respiratory  absence  of  The death  function  death  is  imminent...[that  heart  or  lungs;  i s a c a u s e , not Thus t h i s  lack  is a contributor caring  are  maintains  criteria  i s the  brain  functions  death  there  (1985) i n d i c a t e s  criteria  death  other  irreversible  appear  determined  the  brain  us  in  i s e s s e n t i a l f o r death  by  of  the  first  for determining  d e a t h may  functions  alleges  "simply  the  i s placed  and  for  the  a state  of  to  brain  cessation of  conceptual  the  personal  dead  patient  experience. Interpersonal Interpersonal coined  to  personal  describe beliefs,  dissonance the  oppose  interact.  Hence t h i s  i s a term  this  s i t u a t i o n s where the  perceptions,  behaviours  Dissonance  those  of  opinions,  researcher participants'  knowledge  and  i n d i v i d u a l s w i t h whom t h e y  terminology  can  not  be  discovered  of  ICU  N u r s e s and t h e B r a i n Dead  Patient 133  within  the e x i s t i n g  literature insight  literature.  However, i t i s f e l t  on i n t e r p e r s o n a l r e l a t i o n s h i p s p r o v i d e s  into this  that  some  l a c k o f e x t e r n a l harmony w h i c h e x i s t s  between p a r t i c i p a n t s and, t h e p a t i e n t ' s f a m i l y members, t h e physicians,  the P a c i f i c  Team and n u r s i n g the  to e t h i c a l  literature  process*  care  professions.  between  greater  nurse's  personal  criteria  exist  Muldary  a value  of t h i s  and  of the a l l i e d  w h i c h we  health  established  demands and  (Toffler,  beliefs,  healthy  i n d i v i d u a l s and as i n any  a relationship, on one a n o t h e r t o  1970, p. 9 8 ) .  The  and a t t i t u d e s " a r e t h e  [she] judge[s]  ourselves  [herself]  f o r many o f t h e d i f f e r e n c e s  [ h e r s e l f ] and o t h e r s "  (1983) h y p o t h e s i z e s  values, that  ill  the p a r t i e s exert  values,  when one p e r s o n ' s  negative  other  They a l s o a c c o u n t  between o u r s e l v e s 109).  or i n d i r e c t l y  "...mutual  expectations"  against  others.  exist  the pressure  these  values  as an ' i n t e r p e r s o n a l  The more i n t i m a t e l y i n v o l v e d  fulfill  and  search  A relationship i s therefore  there  expectations.  nursing  f a m i l y , and members  t h e n u r s e and t h e s e  relationship  beliefs  i s s u e s a computer  (1971) d e s c r i b e s  their  around  conducted.  involving directly  individuals,  I n a d d i t i o n , as a number o f  centered  or moral  was a l s o  Travelbee  and  colleagues.  interpersonal clashes  related  the  Organ R e t r i e v a l f o r T r a n s p l a n t a t i o n  i s low i n t h e o t h e r ' s  1983, p.  that " . . . v a l u e - c o n f l i c t s  p o s i t i v e values  o r when one p e r s o n  (Muldary,  are another  places system  high  person's  priority  on  of p r i o r i t i e s " ( p .  ICU  N u r s e s and t h e B r a i n  Dead  Patient 134  206).  The r e s u l t  i s interpersonal  which  "are undesirable  inner  harmony, c a n make us f e e l  miserable, value  because  and i n e s s e n c e ,  in life"  experienced described  (Muldary,  conflict  they  threaten  tension  our sense o f  unhappy and g e n e r a l l y  disrupt  the order  1983, p . 2 0 6 ) .  presented  and b a l a n c e  The p e r s o n a l  by t h e p a r t i c i p a n t s o f t h i s  by t h e a c c o u n t s  and  study  i n the  we  tension  i s well  preceding  chapter. Gadow (1985) r a i s e s t h e p o s s i b i l i t y technology  causing  professional example  a conflict  goals  of c a r i n g  the technology  measures  that  prevent  t h e body  validity  interpretations,  It  n o t upon  further  clinical  care  This  dominance o f  and  physicians)  which  "negates the  a r e based  upon  t h e meanings and c o h e r e n c e  Gadow's p h i l o s o p h y  death with  whom t h e b r a i n  dead  once was.  exists  i n this  s i t u a t i o n i s the c u r i n g  versus  the c a r i n g  of the b r a i n  dead  of the  one s t e p  advances i n  d i g n i t y and p e r m i t  t o be made w i t h o u t patient  external  (Gadow, 1985, p. 3 6 ) .  the t e c h n o l o g i c a l  now p r e v e n t  decisions  object  decisions  to carry  and s a y t h a t  resuscitation  (nurses  by t h e p a t i e n t "  i s possible  as an  meanings o f t h e p e r s o n ' s  clinical  body a s c o n s t i t u t e d  She c i t e s  dignity.  experts  to a s c i e n t i f i c  experience...Thus  between t h e  and c u r i n g .  death with  of s u b j e c t i v e  care  i n r e s u s c i t a t i v e and i n t e n s i v e  m a c h i n e s and t e c h n o l o g i c a l reduces  to e x i s t  of h e a l t h  regard  to the person  The c o n f l i c t of f a i l i n g  patient.  which  organs  Support f o r  ICU Nurses and the Brain Dead Patient 135 this belief is found in one participant's account of how Mr Jones had ceased to exist and was now only a potassium of 3.4. P. ...they [the transplant team] I feel definitely come in and they look at numbers and they look at lines and they don't look at who is attached at the end of that... According to Sheard (1980) the conflict that plagues nurses and physicians even though they work side by side results from each structuring their work in radically different ways and a tendency "to misunderstand the methods and inner logic of one another's work" (p. 14). He describes six basic work dimensions on which nurses and physicians differ.  Two of these dimensions such as a sense  of time and a sense of resources are applicable to this study.  With regard to the former Sheard (1980) sees the  physician as having an "enduring sense of time" (p. 14) in that his/her work is determined by the course of the illness.  Whereas, nurses have "an hourly, strictly  scheduled sense of time" conceived as a twelve-hour day and "organized around a rigid schedule of tasks" (Sheard, 1980, p. 15). This may in part account for some of the interpersonal dissonance the participants experience when waiting for the physician to declare the patient brain dead. In the work dimension involving resources, he sees the physician as having an "abundance view of hospital resources" and this being opposed by nurses who have a  ICU  N u r s e s and  the  Brain  Dead  Patient 136  "scarcity He  view of  believes  "strong  the  fear  of  to e x p l a i n  participant  bias law  which  suits"  some of  the  (Sheard,  when t h e y  physician  to  participant: Aroskar  terminate  experiences 1985,  understanding  life  support time,  (1985) o f f e r s f u r t h e r  "differing  more to  that  p. the  their  47)  physicians and  v i e w s of  and  that  work w o r l d s  [that]  1980,  15).  sense of  lack  this  i s found  commenting states:  of  the  p.  an This  one  conflict on  and  the  i n the  negatively  account on  nurses  of  the  words of  one  resources..." support and  for  have  work  world"  the  "lack and  probably  of of  Sheard's  nurses  the one  physician  of nurses  contributes  in  (Aroskar,  understanding  the  part  i n the  misunderstandings  t h a n many r e a l i z e "  families  to  physicians  relationships  after  in part,  i t i s the  ways i n w h i c h  f r u s t r a t i o n and  experience  15).  assuming t h a t t h i s p a t i e n t and we're c a r r y i n g on then they [the p h y s i c i a n s ]  a hesitancy  "you're wasting  reasons  experience  p.  physicians'  "inconsistencies"  r e l a t e s to  perceive  v i e w s . She  (Aroskar,  1980,  f e e l s when:  abundance view a l s o  report  the  i s due,  P. R i g h t l i k e we're s o r t of i s p r o b a b l y been b r a i n dead e v e r y t h i n g a g g r e s s i v e l y and w i l l do t h e s e t e s t s . . . The  (Sheard,  abundance v i e w s u p p o r t s  conservative  exaggerated helps  hospital resources"  physician-nurse  1985,  p.  49).  other's participant  involvement  who with  A  ICU  N u r s e s and  the  Brain  Dead  Patient 137  P. Of c o u r s e i t ' s easy f o r me on t h i s s i d e of the f e n c e and physicians side. Chapelsky the in  (1981) s u g g e s t s  physician-nurse professional  judgments" nurse  (p.  179).  The  first  loyalties.  confined  to  the  patient,  patient,  the  Aroskar,  1981).  physician The  and  refusing  dead  (page 80)  and  team's e f f o r t s to  obtain  ( p a g e s 83  The  decision  making  orders within p.  180).  From  conflict  of  Director  and  man  who  the  the  an  on  nurse which being  life  findings  existence  of  brain  support of  the  the  the on  a  brain  transplant  recipients over  being  moral  central  i s relegated  exemplary  to  to  following  occur  by  moral c o n f l i c t s  case  three (page  Davis as  Intensive  i n the  for  systems,  situation is  the  of  days i s  1981, the  Care the  Unit young  still  76).  (1989) a l s o  being  1981;  may  framework" ( C h a p e l s k y ,  dead  a study  of  f o r unknown  m o r a l j u d g m e n t s between the  to  that  of  disagreements  nurse  loyalty is  (Chapelsky,  code o r d e r  physician  physician's  t h i s study  despite  maintained The  "while  the  and  professional  obligations  accounts  organs  physician  dissonance  a no  the  second,  around  the  the  institution  to w r i t e  in  moral  physician's  n u r s e has  the  i s inherent  over  p a r t i c i p a n t ' s account  cardiologist  judgments r e v o l v e  the  and  the  interpersonal  i s s e e n i n one  - 87).  While  I'm sitting what's on the  to " i n c o m p a t i b i l i t i e s  involves  d i f f e r e n t personal  and  patient  conflict  disagreements  obligations  result  that  r e l a t i o n s h i p due  r o l e s and  possessing  to say t h a t I c a n ' t see  a  source  support of  ICU  N u r s e s and t h e B r a i n Dead  Patient 138  interpersonal it's  dissonance.  In D a v i s '  study,  g o a l t h e d e t e r m i n a t i o n how n u r s e s  dilemmas,  100 C a n a d i a n  definitions findings  evolved  of t h i s  nurses  and each  study.  define  conflicted  physicians This  i s felt  One group  those  researcher's  of p r i n c i p l e s definition  between  colleagues,  and PORT.  From  of nurses  "saw  'ethical  own p r i n c i p l e s  i n Davis'  nurses what  believe  that  the nurse  institution's be  survey.  or b e l i e f s  i s comparable dissonance  the p e r s p e c t i v e of t h i s  transplantation procedures attempts by  She a l s o  reports that conflict  b e l i e v e s i s necessary  the i n s t i t u t i o n  restraints.  having  a budget  and t h e n u r s e  as a t t e m p t s  one p a r t i c i p a n t  of t h i s  care.  this  might  f o r good  A corollary  study referred  group o f  exist  between  c a r e and t h e of t h i s  f o r a program  viewing  to m a i n t a i n  to provide p a t i e n t  to t h i s  and p h y s i c i a n s , n u r s e  an e t h i c a l  budget  or  ( D a v i s , 1989, p. 8 7 ) .  PORT c a n be c o n s i d e r e d t o r e p r e s e n t t h e i n s t i t u t i o n to  distinct  t o be r e l e v a n t t o t h e  of i n t e r p e r s o n a l  the nurse  Three  of other nurses, s u p e r v i s o r s ,  or the i n s t i t u t i o n . . . "  conflict  occurring  with  ethical  were s u r v e y e d .  dilemmas' a s a c o n f l i c t when t h e n u r s e ' s beliefs  w h i c h had as  could  such as  the organ h a r v e s t i n g  that  budget  This feeling  and n o t as i s expressed  study.  P. I t h i n k t h e y (PORT) a r e t r y i n g t o meet t h e i r numbers so t h a t t h e y c a n meet t h e i r budget and g e t t h e same budget n e x t y e a r w h i c h I'm n o t s u r e t h a t I a g r e e w i t h but...  ICU  Nurses  and  the B r a i n  Dead  Patient 139  A second  group  dilemma as " t h e begins  and  (Davis,  grey  ends,  1989,  participants  o f D a v i s ' s u b j e c t s d e f i n e d an a r e a of d e c i s i o n  the q u a l i t y p. 8 7 ) .  The  demonstrate  the p h y s i c i a n s h e s i t a t e brain  dead  decision  patient  inappropriate than  (Johnstone, A third ethical was  also  group  corresponds  nurse's  One  of n u r s e s "conduct  p. 8 7 ) .  to t h i s such  to accept  their  this  more e m o t i o n a l l y and Quint  having  issues,  the  members i n the  by  should  be  the n u r s e s  as  o f " n o t h i n g more  of r i g h t  and  wrong"  T h i s type  rationally  of e t h i c a l  findings  dilemma  interpersonal  i s the a c c o u n t  of a f a m i l y ' s  death  intellectually this  may  with death,  from  of  conduct  of  d i e i n the h o s p i t a l , shielded  when someone's  instead  confrontation  more f a m i l i a r i t y  increasingly  on  when  Davis' survey d e f i n e d  daughter's  brain  (1966) i n d i c a t e s  individuals  support  violations  from  study's  example  knowledge about  (1985) b e l i e v e  or d i s s o n a n c e  viewed  or p e r s o n a l s e n s e  ( D a v i s , 1989,  inability  and  and  role"  p.83).  dilemmas as  dissonance.  al  ( Q u i n t , 1967)  life  study's  the v e n t i l a t o r  are  c o n s i d e r e d e m o t i o n a l l y based  based"  family  or not  These d e c i s i o n s  1989,  of t h i s  conflict  the  on where  the n u r s e ' s  to t e r m i n a t e l i f e  or i n c l u d e  a philosophical  and  accounts  similar  r e g a r d i n g whether  disconnected.  of l i f e  based  ethical  death (page  clashing 72).  with  Youngner  o c c u r s as n u r s e s prepared be  to a c c e p t  related  as more and  whereas  the d e a l i n g  the  with  to  family i s death.  et  are death  nurses  more  the  ICU Nurses and the Brain Dead Patient 140 Distancing The findings of this study indicate that distancing is a process by which the participants place some psychological distance between themselves and the brain dead patient or in some instances the family members. The participants see distancing as a necessity in order to separate their work life from their home life, to continue to function in the intensive care unit and to protect themselves emotionally. It is a method of coping with the personal or interpersonal dissonance they are experiencing. Within the literature various synonyms for distancing such as withdrawal, avoidance, therapeutic distancing, defensive distancing, professional distancing, emotional distancing and physical distancing are found.  In addition,  distancing is discussed in a variety of contexts.  It is  seen as a coping mechanism used by nurses and other health care personnel to deal with a stressful situation such as death and dying (Conboy-Hill, 1986; Davitz & Davitz, 1975; Hay & Oken, 1972; Larson, 1987; Maguire, 1985; Murphy, 1986; Quint, 1966; Stehle, 1981; Travelbee, 1971;) It is considered to occur as the result of burn-out which is related to a culmination of job related stresses (Beland, 1979; Muldary, 1983) or is discussed in the setting of busy health care workers attending to the disease and not to the person (Mechanic, 1972; Roberts, 1986).  ICU  N u r s e s and  the  Brain  Dead  Patient 141  In living  a l l instances, patients  distancing  or  distancing  patients  t a c t i c s used  patient  could  authors  view d i s t a n c i n g  easier  found.  faceless,  a problem  harm to 1983,  To  date  is  his  family  members.  literature  much can  been  for  to  facing to  to Hay  function  intensive  in  the  guilt,  But  meaning and p.  dead  important  point  as  because  that  into is  be  brain  proven  dead  a  to  cause  (Muldary,  that  patient  t h i s void to  some  nothing  who-cares-anyway?'" to  to  " i t i s much  I t i s much e a s i e r  the  114).  distancing  she  ICU  rage, and  do  care  unit  in  t h i s study  and  posing  to  avoid,  or  even  the from  what  t h i s they  techniques.  see  i s "the of  major repetitive  object to  loss  continue  h e r s e l f - from  grief,  overcommitment,  at  of  the  i n order  "protect  or  109)  threats  r e s t . She  impact  p.  nurses  Consequently,  a l l the  can  (1972,  exhausted  emotional  To  Oken  dying,  failure."  overstimulation escape.  for a  organism  extrapolated  and  d e a t h and  personal  anxiety,  caring  However d e s p i t e be  reference  been dehumanized  i t remains to  No  distancing  According  exposure  has  i n r e l a t i o n to  written.  Rationale  and  negative  space.  'harmful'  to  i s an  'what's-his-name,' and  p.257).  problem  up  dying.  regard  This as  are  insignificant  taking  distancing  has  with  to harm someone who  nameless, but  be  who  i s explored  They a l s o  no  physical  least attenuate,  her  the  has  work" (Hay  nurse  & Oken,  employing  indicate  that  the 1972,  defensive  another  ICU  N u r s e s and  t h e B r a i n Dead  Patient 142  reason and  for distancing  having  patient's  to c o n t i n u e outcome.  dissonance  referred  Davitz interviews  and  interviews  asked  repetitive  in  not  stability  found  build  distance"  participants  anonymously  discovered  nurses  -  86).  group  practicing  effects  of  study's study's that  this  also  findings  and  typically  that  of  exposure  represent  being were  their  own  against  are  the  D a v i t z and  Davitz  emotional  in professional  involve  reaction  These b e l i e f s  participants.  "to maintain  in  the  indicate  repeated  a t home.  effective  of  l e a d s to a sense  p s y c h o l o g i c a l defenses  (1987) a s k e d  495  practice,  overinvolvement.  establishing  conferences  nurses and  w r i t e down s e c r e t  would that  in this  or h a v i n g  small  Their findings  to s u f f e r i n g  remain  professional  they  female  85  some  emotional  (p.1508).  Larson  secrets  200  (pages  to d e s c r i b e t h e i r  the  These d e f e n s e s  that  Four  the  interpersonal  the  The  and  patient  A component  o f the  (1975) a l s o  in  to i n Chapter  o n l y a t work but  sentiments  f o r the  York h o s p i t a l s .  exposure  accord with  nurses  the  of a p a t i e n t .  overwhelmed. felt  This reflects  D a v i t z (1975) c o n d u c t e d  New  suffering  caring  t o p r o v i d e c a r e d e s p i t e knowing  w i t h more t h a t  metropolitan  to  i s the n u r s e  not  feel  actually  one  were  participating  e d u c a t i o n a l programs  thoughts  comfortable  "more t h a n sample  who  out  contained  related  to  to t h e i r  sharing openly.  of e v e r y  five  descriptions  e m o t i o n a l l y or p h y s i c a l l y  work  He  helper  of w a n t i n g distanced  to  ICU  N u r s e s and  the  Brain  Dead  Patient 143  oneself family  from  patients,  patients'  members" ( p . 2 4 ) .  distancing  tactics  families,  These e m o t i o n a l  were a t t e m p t s  staff  and  or  personal  physical  at  decreasing  as  e i t h e r an  emotional  involvement. Most physical of  the  authors  separation  patient Muldary,  given  the  nurse  i s assigned  is  not  by  detachment  or  the  patient  1979,  Quint,  of  Hay  bedside  I n d e e d , as  the  and  physical  a  unit  or  depersonalization  Roberts,  care  patient  or  emotional  & Oken, 1972;  1966;  intensive  one  possible.  distancing  from  1983;  nature  patient's  distancing  (Beland,  1987,  the  see  Larson,  1986).  nursing  However,  where  the  i s physically stationed  separation  evidenced  from  the  i n Chapter  participants involves  either  at  patient Four,  the  emotional  depersonalization.  Detachment Beland burn-out slight  or  (1979) b e l i e v e s  and  that  the  profound.  detachment  d e g r e e of When the  i s a consequence  detachment  detachment  may  be  is slight  of  either this  permits: ...just  enough e m o t i o n a l  evaluate  the  objectivity This  situation i n order  detachment  involved Emotional  with  the  mean t h a t  on  the  Quite part  the the of  patient  to  greater  to more r e a l i s t i c a l l y  patient.  involvement  from  from a p o s i t i o n o f  does not  the  distance  plan  nurse  is  care. not  contrary. the  nurse with  the  ICU  N u r s e s and t h e B r a i n  Dead  Patient 144  patient  may  distancing But  be an e s s e n t i a l p r e c u r s o r o r detachment  to maintain  distance  oneself  following  of  therapeutic  ( p . 199)  some e m o t i o n a l  is difficult  involvement  and t o  as i s i l l u s t r a t e d  by t h e  account.  P. I t r y t o a c e r t a i n e x t e n t um d e t a c h m y s e l f t o a p o i n t where I want t o be s u p p o r t i v e f o r t h e f a m i l y b u t t h e r e i s a f i n e l i n e o f p e r h a p s o f g e t t i n g i n v o l v e d and s t a y i n g on t h e o t h e r s i d e . . . This  p a r t i c i p a n t ' s attempts  with Larson's find  (1987) p h i l o s o p h y  a way t o be e m o t i o n a l l y  families helping  that  profound part  there  that  automaton w i t h o u t  study  "through  brain  feeling  dead  and This  with  that  concur  with Beland  not i n t o donor  p a t i e n t s and  24).  when t h e d e t a c h m e n t i s distancing  to f u n c t i o n concern  To a d e g r e e i n that care  unique  as an f o r t h e needs  the f i n d i n g s of  t h e n u r s e may be g o i n g  of the p a t i e n t  as an " a c a d e m i c  b u t I am  distinguishing feature  f o r whom t h e n u r s e s  i n the f o l l o w i n g  of the  exercise". of t h i s  are caring  accounts.  study i s  a r e dead  t h e p a r t i c i p a n t s do n o t s e e them a s p o s s e s s i n g i s evident  on t h e  i t " o r t h e n u r s e may view t h e c a r e  patient  the p a t i e n t s  nurse...must  one's  (p.  or evident  ( p p . 199 - 2 0 0 ) .  However, t h e c r u c i a l that  she b e g i n s  the motions of t a k i n g  certainly  with  e x i s t s " s o much e m o t i o n a l  of the nurse  this  involved  believes  are consistent  "every  and n o t o v e r w h e l m i n g "  (1979) a l s o  patients"  that  i s h e l p f u l , congruent  style,  Beland  of  a t detachment  needs.  ICU  N u r s e s and  the B r a i n Dead P a t i e n t 145  P. I t h i n k the f a c t t h a t t h e r e i s no hope, I mean once a p e r s o n i s b r a i n dead t h a t ' s i t . T h e r e i s n o t h i n g l e f t . . . t h e r e i s no u s e . You've r e a c h e d your end. Y o u ' r e not g o i n g t o do a n y t h i n g t h a t ' s g o i n g t o make any d i f f e r e n c e .  P. So am  I mean t h e r e i s a p e r s o n b u t . . . t h e y ' r e not v i a b l e . i f t h e y ' r e not v i a b l e i t seems t h a t no m a t t e r what I g o i n g t o do i t ' s not g o i n g t o change i t .  P. I don't w o r r y a b o u t them [ t h e b r a i n dead p a t i e n t ] any more b e c a u s e t h e y ' r e gone. T h e y ' r e beyond anything. Consequently, connotations detachment  that and  this  researcher  which B e l a n d  are  not  (1971) and  the  by  death  manner i n w h i c h  "is  t o w i t h d r a w from  the  feeling  detachment  that  nurse  with  the  the  nurse  the  become p r o t e c t i v e from  may  or  i n the  own  this  (1975)  infer  suffering of o t h e r s  these  or s i t u a t i o n  situation"  impact  and  encounters producing  I n d i f f e r e n c e or  mechanisms i n t h a t t h e y full  study.  vulnerability.  deal with  detachment.  e x p e r i e n c i n g the  i s engendered  of  to i l l n e s s ,  her  individual  of i n d i f f e r e n c e  Davitz  negative  profound  vulnerability  comes f a c e t o f a c e w i t h  One  the  exposure  to  findings  D a v i t z and  repeated  i s confronted  therefore  (1979) a t t a c h e s  a p p l i c a b l e t o the  Travelbee nurse  b e l i e v e s t h a t the  of  the  prevent  anxiety  ( T r a v e l b e e , 1971,  p.  41). The provision aware o f  participants of care their  own  to  of the  this brain  mortality.  study dead  do  indicate  that  the  p a t i e n t makes them more  ICU  Nurses  and  the  Brain  Dead  Patient  146  P. M o r e a w a r e e v e n t h o u g h I n e v e r e x p e c t a n y t h i n g to h a p p e n t o me o r t h e p e o p l e t h a t I c a r e a b o u t . I know i t h a p p e n s t o f a m i l i e s a l l t h e t i m e a n d I know i t ' s t h e r e a n d I know i t c a n h a p p e n a n d I know everything c a n c h a n g e s o q u i c k l y a n d I j u s t know t h a t . . .  P. L i f e ' s , l i f e ' s way t o o s h o r t a n d way too t r a g i c and don't leave anything t h a t you w o u l d n ' t want l e f t tended t o . . . Y o u t h i n k o f y o u r own [ m o r t a l i t y ] and you t h i n k o f a n d y o u do t h i n k o f t h o s e p e o p l e who are c l o s e to you. And i t ' s n o t i n a m o r b i d way. J u s t makes you think t w i c e t h a t i t c o u l d h a v e b e e n THEM. So I t h i n k i t makes you e v a l u a t e y o u r r e l a t i o n s h i p s and I t h i n k y o u r f r i e n d s and y o u r f a m i l y and I t h i n k i t makes you think t w i c e a b o u t them.  P. I t m a k e s y o u v e r y a w a r e y o u c a n be h e r e one minute a n d g o n e t h e n e x t . ' I t ' s a l s o made me h a v e a l i v i n g w i l l a n d . . . I h a v e t a l k e d t o my f a m i l y a b o u t i t t h a t you know t h a t i f s o m e t h i n g h a p p e n e d t o me I w o u l d n ' t w a n t t o be l i f e s u p p o r t e d . . . i f I t h i n k o f i t t h e day that I d i e a n d I go t o h e a v e n I s u r e d o n ' t w a n t t o stand b e f o r e God a n d h a v e Him s a y : " W e l l you s u r e d i d shitty t h i n g s t o p e o p l e " . . . i f I was b r a i n dead I'd want p e o p l e t o h a v e r e v e r e n c e f o r m e . . . C a u s e y o u know w h a t I do f o r m y s e l f or t o o t h e r s I w o u l d want done to me. Though mortality they,  these  or  greater  Travelbee's  withdraw  demonstrates  seen her  as  from  appreciation  Travelbee's  do  vulnerability  unlike  awareness,  nurses  an  statement  their  belief, the life  regarding  relevant that  to  do  not,  as  with  the  the  own  indicate  Instead  cause  a  their  because  the  study. is  of  accounts  and  this  detachment  aware  patient.  identification  belief  being  for  become  last  that  of  they  obtain  account  patient.  Hence  of  detachment  On  the  protective  this  other  is  not  hand,  mechanism  is  a  ICU  Nurses  and t h e B r a i n  Dead  Patient 147  applicable. accounts  Supporting evidence  i s found  i n Chapter  from  the p a r t i c i p a n t ' s  Four.  Depersonalization Within  the l i t e r a t u r e  depersonalization exception  functions sees  of  disorders"  the s e l f  felt  t o be r e l e v a n t  Howard  symbolizes  " t h e r e i s an  This last  point seen  of dehumanization that  (p.59) and t h a t  a s : (1) people  dehumanization  problems,  (5) people  degradation, recipients people  patients  the concept  sterile  with  environments  people:  as i s o l a t e s ,  of substandard  that  or p r o f e s s i o n a l s has e l e v e n  by t e c h n o l o g y ,  as l e s s e r  found  or d e p e r s o n a l i z a t i o n  (2) people as as g u i n e a  ( 4 ) p e o p l e as  dehumanization  by  ( 7 ) p e o p l e as  c a r e , (8) people  as o p t i o n s , ( 9 )  i c e b e r g s , (10) people  and ( 1 1 ) p e o p l e  different  meanings she  (3) people  by e x p e r i m e n t a t i o n ,  (6) people  interacting  i s not  i n the  as t h i n g s ( t h i n g i n g ) ,  machines: dehumanization pigs:  o f view  of the l i t e r a t u r e  meanings a t t a c h e d t o i t . T h e s e a s s o c i a t e d outlines  absence  study.  negative states  experience"  syndrome f o u n d i n  (p.278) i n w h i c h  (1972) i n a r e v i e w  concept  "as  t h a n a human" ( p . 277) and  to the d i s t a n c i n g  of t h i s  An  o f human c a p a c i t i e s and  as "a complex  image" ( p . 2 7 8 ) .  participants  "The  the person  he becomes l e s s  depersonalization  emotional  interchangeably.  (1986) who d e f i n e s d e h u m a n i z a t i o n  of d i v e s t i n g until  o f a u t h o r s use t h e terms  and d e h u m a n i z a t i o n  i s Roberts  the r e s u l t  a number  denied  in static,  p r e s e r v a t i o n of  ICU  N u r s e s and  the  Brain  Dead  Patient 148  life. are  Of  t h e s e meanings o f  relevant  discussed. concept  The  of  health  coping  is  care  other  the  of  first  f i n d i n g s and  now  be  meanings  they  system  mechanism of  though  on  the  nurses  to  individual  dealing person  being  depersonalization  pertinent  more the  with  i s obvious  two  the  different  rather  effects  than  personal  and  (Howard,  a  which  this  object  1972).  i n the  two  there.  A  of  stress.  object  experience  a doer  to  overall  becomes an  for subjective  opposed  will  have a somewhat  reflect  means the  capacity  done to as  form  study's  i n that  "Thinging" lacks  the  the  depersonalization  connotation the  to  depersonalization  This  following  accounts. P.  It's just  a receptacle  lying  container...  P. I t h i n k i t ' s a n o t h i n g . . . i t ' s not f u n c t i o n i n g we're d o i n g a l l the work f o r i t . . . N o I d o n ' t t h i n k of i t as anything. E x c e p t f o r s o m e t h i n g t h a t I am maintaining ah s o m e t h i n g l i k e a b o a r d or w h a t e v e r . This meaning  last  of  through  extension  harvesting  account  These a c c o u n t s of  by and  supports  P. So i t ' s j u s t then.  definition  where due  of a m a c h i n e .  dehumanization  the  following  a l s o h i n t s at.Howard's  dehumanization  becomes an indicates  account  an also  (1972) s e c o n d  to  technology  In  a d d i t i o n , Howard  technology  can  also  t r a n s p l a n t a t i o n of this  person  occur organs.  The  view.  a c a d e m i c mass t h a t ' s support  the  Beland's  dehumanization which  she  going  to  (1979, p.  s e e s as  a  the 199)  process  OR  ICU  N u r s e s and  the  Brain  Dead  Patient 149  "where the  one  qualities."  person  However, she  possible  r e s u l t of  physical  separation  this  point  point upon  of the  referred  divests  that  also  detachment to  the  the  but  do  view t h a t  the  nurse  patient.  For  instance,  to  the  brain  dead  of  h i s human  views dehumanization  contempt"  findings  other  goes beyond (1979,  not  p.  200).  participant  as  and  I t i s at Beland's  passes adverse moral  patient  "the  emotional  substantiate  the  as  judgment who  a "board" a l s o  states:  P. I t r e a t them [ t h e b r a i n dead p a t i e n t ] the same way as I would somebody t h a t was awake...I'm s t i l l c a r i n g and I g i v e them a l l the c a r e t h a t t h e y . . . t u r n them, g i v e them mouth c a r e and I t a l k to them even i f t h e y can't hear. This  datum c l e a r l y  brain  dead  feelings  patient  about  participant stress  care  patient's the to  to  created  provide  i s not  the  distance by  and  the  brain  depersonalization  h e r s e l f i n order  the  destiny.  (1983) who  and  to  attempt deal  not  will  This  same p a r t i c i p a n t i n the  inner by  with  having  affect  the  the  the  to  the indicates  provision  of  care  patient.  opinion  believes  "converted  an  of  nurse's  care  P. Then maybe the w o r s t t h i n g o f f and s a y i n g t h a t i s i t and be done. Another  the  s i t u a t i o n of  f r u s t r a t i o n found  dead  of  I t i s simply  dissonant  knowing  and  that  a reflection  patient.  ultimate  futility the  indicates  on that  i s a c t u a l l y s h u t t i n g them t h e r e i s n o t h i n g more to  dehumanization patients  into disease  by  Muldary  are:  entities,  somehow synonymous w i t h  i s held  the  devoid  of  afflictions  humanity, of  their  ICU  N u r s e s and  the  Brain  Dead  Patient 150  bodies...One they  didn't  reduced  result  i s that  m a t t e r . . . Once we  them to  subhuman or  that  may  to  them.(pp. 255  This  c o n v i c t i o n of M u l d a r y  harmful  nurse  patient.  Suppose  the  patient  believes  patient  i s "harmful"  depersonalizing  continuing  once e x i s t e d  harvesting  of  organs  or  i s created  to her  beliefs.  personal  patient  she  longer  being  can  then  This  Designating  sought  to  the  of  Another  years  identify  there the  Part  the  nursing  r e c i p i e n t of  describing patient (p.  75).  her  her  of  as  - it  our  parts  brain brain  dead dead treat  the  d i s r e s p e c t f u l to  the  believes brain  that dead  actions  are  dehumanizing i n that  are  not  the donor.  opposed the  the  person  construed  specifically  as  address  Target  of Nursing  Care  have been many d i s c u s s i o n s  this  of  of n u r s i n g  i n the  best  condition  nursing  quest  care?  goal  her  d i d not  -  256)  the  actions  actions  the  the  Within  people  an a l t e r n a t i v e  the  her  as i f  dehumanization.  essence  what i t i s n o t .  to  However, by  research  conceptualization  she  i n that  exists therefore  harmful.  Over  perhaps  justify  -  f o r the  being  i s "harmful"  Then d i s s o n a n c e  on  to v e n t i l a t e and  i n terms of  p e r s o n who  actions  provides  nurse c a r i n g  that  treated  nonhuman e n t i t i e s  justify  be  then  have dehumanized  to  f o r the  this  are  becomes much e a s i e r  rationale  no  they  - what i t i s  i s concerned  Nightingale  definition,  put  to a c t  Nightingale  with  and who  (1859) when  s a i d i t " i s to for nature  which  the  upon  gives  him"  is  ICU  N u r s e s and  the  Brain  Dead  Patient 151  recognition But  to  the  what i f the  patient  then  essence  of  help  those  put  her  i n the  i n the  belief  persons,  activities  of  face the  246).  This  die with statement  nursing  care  nursing  stops  as  Leininger "promoting illness  and  the  a recipient these  that  the  of  revolves  for l i f e  to  those  and  also  nursing  is  to d e a t h ,  with  or  their  regain  irreversible i s i n e v i t a b l e (p. the  target  of  i n d i c a t e s that  nursing  behaviors  to an then  being  the  focuses or  recovery  nurse  around  social  patient  study's  articulate  a living  5). does  not  When  no  the  dissonance  i s present. may  c o n c e p t u a l i z a t i o n of n u r s i n g  of  human b e i n g .  who  care  participants  a concept  individual  p r o v i s i o n of n u r s i n g  from  care.  scholars, this  one  on  a s s i s t e d " (p.  b r a i n dead  of n u r s i n g  nursing  i s provided  the  health  definition  exception  capacity  with  by  as  Like  which  but  the  technology  w h i c h have p h y s i c a l , p s y c h o c u l t u r a l , and  this  care  gain  identifies  person  maintaining  Obviously  nursing  this  can  f u n c t i o n of birth  (1984) i n d i c a t e s t h a t  or meaning  with  How  death.  significance  qualify  unique  handicaps  only  actions.  of a d v a n c i n g  living...to  not  nurse's  preserving  d i g n i t y when d e a t h  a living  with  on  or w e l l , from  daily  of  condition?  address  i n d e p e n d e n c e . . . to cope w i t h disease...to  focus  i s dead?  best  that  sick  the  patient  (1980) i n an  nursing  reinstated "to  assigned  be  Henderson  p a t i e n t as  longer  A manner  become  i s to  has  congruent  designate  by  ICU  N u r s e s and  the  Brain  Dead  Patient 152  another, as  the  that  i s , a third  target  of  participants'  accounts  the  transplant  The  family In  actions.  this  the  peripheral  the  to  family  as  family  thereby  in  how the  1988;  an  with  nurses  can  literature McCorkle,  the As  how  part  of  the  to  intensive  a d e s c r i p t i v e study  of  the  units.  Out  of  nurses,  226  (82%)  of  the  to  a convenience returned  represented  critical  n u r s e s had  the  patient. brain  dead  patient  well  1985;  addressed  Kozlowski,  However, v e r y nurses  care  care  to  little  view t h e i r  the  eleven units.  experience  and  nurses  sample  explore  nurses  nurse, Hickey  a questionnaire  pediatric  the  is  role  family.  distributed  respondents  unit  into  helping  t h e s e needs a r e  care  taken  (1971) v i e w s  i n that  or  1985).  family,  i s i n many ways  (Goldsmith & Montefusco, Weber,  the  though  care,  a s s i s t s the  respond  be  the  care  family,  dying  by  nurse h e r s e l f .  patient  between c r i t i c a l  perspective  the  Travelbee  f a m i l i e s of  1982;  patient's  relationships the  indirectly  needs of  known a b o u t  of  evidenced  p e r s o n may  nursing  situation.  extension  As  nursing  h o s p i t a l s e t t i n g the when p l a n n i n g  and  even  r e c i p i e n t of  consideration  The  third  r e c i p i e n t , or  as  the  nursing  individual, a living individual,  of  and  i n 18 275  critical critical  d i f f e r e n t types  with  the  be  families  Lewandowski  questionnaire.  I t can  the  (1988) care care  The of  assumed  brain  from  dead  adult that  and some  patient  and  ICU  N u r s e s and  the  Brain  Dead  Patient 153  his  family,  11%  were One  critical  10%  question care  nurses  a majority  of  emotionally  the  to  expect  staff  of  family  Lewandowski,  to  of  the  1988,  nursing  family, care,  the  become i n v o l v e d The  fact  already family  the  can  patient  transplant Youngner  opportunity  to  marvelous g i f t  for  the  Though  it  was  families,  with  family  realistic  emotional  i l l patient"  16  (Hickey  to  needs  &  672). Lewandowski's s t u d y  opposed  does not  patient,  i s the  f i n d i n g that  the  majority  of  the  family  majority family  of  i s considered  critical  provides  become the  center  care  target  nurses  of  do  important.  nurses  are  i n s i g h t i n t o how of  state  nursing  care  the when  the  i s dead.  r e c i p i e n t as (1985) s t a t e s turn of  to c a r e  i t was  the  the  the  easily  that  of  included  that  with  do  p.  relationship.  indicated  believe  "How  1988,  to  with  nursing  assigned The  that  as  s c a l e which  become i n v o l v e d  critically  Though H i c k e y ' s and the  and  families  & Lewandowski,  (77%)  still  nurses  p.  r o l e s with  become i n v o l v e d  " d i d not  critical  to answer was:  nurse-family  respondents  38%  own  a Likert  the  t h e y would  Only  sought  (Hickey  used  exhausting  responded  members.  authors  view t h e i r  question related  that  u n i t s were m e d i c a l - s u r g i c a l  i l l patients?"  This  the  the  the  statements  86%  of  neurological-neurosurgical.  critically 670).  as  the  of  care  "transplantation  a personal  life  target  and  for others.  familial  provides tragedy  an  into  I t i s a u n i q u e way  to  a  ICU Nurses and the Brain Dead Patient 154 affirm and share our humanity" (p. 322 - 323).  For some  participants to be able to designate the transplant recipient as the target of their nursing care provides them with a goal for their care and personal rewards in knowing that they are helping to benefit another.  In Sophie's et  al. (1983) study 86.8% of the respondents indicate that they approve of organ donation and of these 76.7% cite the benefit of transplantation, that is, the knowledge that donation would provide the recipient with hope as the factor which led to their support. Nursing the nurse Pines, Aronson, and Kafry (1981) reflect that while most human relationships have a give and take component, health care relationships possess a client-centered orientation in that the health care worker gives and the patient receives.  Benner and Wrubel (1989) question the  need for caring relationships to be totally altruistic: However, in a phenomenological view of the person, in which the person is viewed as related to others and defined by those relationships, concern for others is not necessarily oppositional to or competitive with self-interest.  Concern for others may bring about  mutual realization.  Caring for others contributes to a  world where one can care and expect to be cared for (p. 367).  ICU  N u r s e s and  the  B r a i n Dead P a t i e n t 155  Indeed the  a few  of  this  study's  basic nursing care a c t i v i t i e s  dead  p a t i e n t are  themselves  feel  in reality good  sense  o f humanism.  those  reported  disclosures  by  or  provided  by  indicate  they  f o r the  done f o r t h e m s e l v e s .  findings  are  (1987) who  need  recognized Muldary, health those  f o r nurses  i n the  1983;  nurses  care of  of h e a l t h c a r e  recipients"  burn-out  Muldary  and  restoring  must meet her  own  they  one's own needs..."  of  the  22). i s well  (Beland,  1979;  (1983) s t r e s s e s t h a t for their  would  should  own  expressions  f o r themselves  (p. v i i i ) .  t h a t more a t t e n t i o n  protecting nurse  c o l l e a g u e s as  their  to g i v e " (p.  p r o f e s s i o n a l s "must c a r e  their  contends  1981).  on  brain  make  t h a t 3%  "contain direct  to c a r e  literature  Pines,  To  that  c o n s i s t e n t with  indicates  of a d e s i r e t o r e c e i v e - as w e l l as The  provide  even sometimes m a i n t a i n  These Larson  participants  care  given  emotional (p.  needs  f o r the  Beland  be  own  and  needs  (1979) " t o ways of balance.  The  200).  Summary Within discussed process  this  chapter  in relation  evolved  the  t o the  findings  study  are  pertinent literature.  As  i t became a p p a r e n t  information  available  Though t h i s  study's  corresponds  to F e s t i n g e r ' s t h e o r y  only  one  study  uncovered.  As  on  the  that there i s  dissonance  concept  of  with  of p e r s o n a l  regard  this  limited to n u r s i n g .  dissonance  of c o g n i t i v e d i s s o n a n c e ,  applying this  theory  to n u r s i n g  a consequence  t h e r e was  a review  was of  the  ICU  N u r s e s and  the  Brain  Dead  Patient 156  literature studies review the  and  death  and  anecdotal  dying  experiencing  to  the  dying  As  this  dissonance' existing  or  to  relationships  and  that  the  which r e l a t e d  concepts within  the  permitted  an  the  felt  to  that  i s written  be  on  to  experience  For  instance,  the  the  patient  views  that  contempt  are  important  literature  and  the  the  the  patients,  of that  not  The  living  to  providing  within  the  interpersonal  allow  of  this the  the  researcher  findings  to  to  is felt  caring  whereas,  i s that the  study's  to  be  findings  relevant  for a brain may  of  substantiated  findings  distancing  are  However, not a l l  distancing  difference  on  s t a t e m e n t s made  findings.  depersonalization  findings.  on  on  study's  Many of  distancing  participant's  reality  found  literature  comparison  others.  applicable  or  the  abundance of  works of  did  made  literature.  in-depth  with  be  when  this  'interpersonal  However, w r i t i n g s issues  From  of  patient.  term  to  number  i s references  dead  the  limited  death.  conflicts  expected  ethical  relative  the  brain  brain  make i n f e r e n c e s  The  also  there  coined  not  literature.  on  internal  researcher i t was  and  reports  i t became a p p a r e n t  nurse  care  on  by  with the  latter  dead  lead  the  to  patient.  to harm  patient  the  the  to  is in  study's  regard former  to is  the focusing  i s concerned  with  dead. The  literature  designating  a third  was  sparse  party  as  regarding  the  recipient  the of  concept nursing  of care.  ICU  N u r s e s and  the  B r a i n Dead  Patient 157  Beliefs  o f a few  existence not  expert  o f d i s s o n a n c e when t h e  f i t with  the  to c r i t i c a l  life',  and  the  own  the  family, transplant  to e x i s t i n g  point  dying  of view the  the by  distancing  be  the  applicable  a void  theories.  t o be  the  the  'gift  nurse  h e r s e l f as  that  this  Finally, with  selects  the  study c o n t r i b u t e s  to  From  considered  to  study  and  to o t h e r  a r e a s of  nursing.  on  and  interpersonal  death  knowledge. for  Fourth,  the  viewing  findings regarding  philosophy  supplies  the  personal  literature  the  the  of  s t u d y makes  Second, the  in existing  r e c i p i e n t of care  information  t o why  a d i f f e r e n t perspective  dissonance associated  the  inconsistencies.  of d i s s o n a n c e .  tactics.  i m p o r t a n c e of  study's f i n d i n g s also contribute  f i n d i n g s enhance the  filling  does  care.  this  a framework f o r s t u d y i n g  study provides  and  First,  nurses deal with  c o n f l i c t s w h i c h may Third,  i n s i g h t as  r e c i p i e n t and  knowledge.  the  of n u r s i n g  c o n c e p t of  several contributions  pragmatic issue  provides  The  to  p r o f e s s i o n a l s need t o meet  r e c i p i e n t s of n u r s i n g  k n o w l e d g e o f how this  philosophy  n u r s e s , the  recognition that  There are  the  care  needs p r o v i d e s  alternative  credibility  r e c i p i e n t of c a r e .  family  their  n u r s e s add  the  o f what n u r s i n g  a f u r t h e r fund  when d e v e l o p i n g  of  nursing  is  ICU Nurses and the Brain Dead Patient 158 CHAPTER 6: SUMMARY, CONCLUSIONS AND IMPLICATIONS FOR NURSING In this chapter the study will be summarized and the conclusions arising from the findings will be presented.  In  addition, the implications for nursing practice, education and research will be delineated. Summary of the Study Advances in biomedical technology have resulted in the ability to artificially maintain 'life' independent of brain function and the creation of a new category of dead patients - the brain dead.  The continuing drawn-out existence of  these brain dead patients in intensive care units is related to a reluctance by lay populations to accept brain death as being synonymous with death (Klein, 1982), the subsequent hesitancy by physicians to withdraw treatment (Black & Zervas, 1984), and the unrelenting medical demand for transplantable viable organs from heart beating cadavers (West 1986, Youngner et al., 1985).  The consequence is that  nurses who were once solely concerned with the administration of care to the living and the dying are called upon to provide care to dead patients. Pertinent findings from the literature indicate that nurses working in intensive care units have a strong commitment to saving life (Goldsmith & Montefusco, 1985; Sophie et al., 1983) and a resultant difficulty accepting death and view it as a personal loss and failure (Caughill,  ICU Nurses and the Brain Dead Patient 159 1976; Goldsmith & Montefusco, 1985; Lippincott, 1979; Quint, 1966; Sophie et a l . , 1983).  Though there is a scarcity of  information related to the experience of providing care to the brain dead patient, there is an indication that nurses find the care emotionally and physically demanding (Borozny, 1988; Sophie et a l . , 1983).  In addition, a recent study by  Youngner et al. (1989) indicates that health care professionals have a lack of conceptual clarity regarding brain death.  These few findings and the overall dearth of  information on the subjective perceptions of nurses providing care to the brain dead patient indicate a need to study this phenomenon from the perspective of the intensive care unit nurse in order to f i l l a void in our existing knowledge. Phenomenology was the research method selected for this study.  Because the intent of this research method is to  understand the experience as it is lived (Anderson, 1989; Knaack, 1984; Lynch-Sauer, 1985; Oiler, 1982; Oiler, 1986; Omery, 1983), it was considered to be the most appropriate methodology for determining the meaning intensive care unit nurses attach to their caring for the brain dead patient. The eleven Caucasian female participants of this study work in the intensive care units of a tertiary and a quarternary care hospital within the greater Vancouver area. They ranged in age from the twenties to the forties.  They  represented five religious denominations and one indicated  ICU  Nurses and  the B r a i n Dead  Patient 160  she  had  no  religious a f f i l i a t i o n .  between two provided  cared  for had  interviews  six  f o r more than ten b r a i n dead p a t i e n t s . twice and  All  s i x were i n v o l v e d  to v a l i d a t e the r e s e a r c h e r ' s  analysis  in  of  data. Data a n a l y s i s was  both a r e f l e c t i v e and  process. From each t r a n s c r i b e d delineated  interview  An  interviews,  the derived  the  the b r a i n dead p a t i e n t .  meaning u n i t s , and  a r e s u l t of the f i n d i n g s , the  experience of c a r i n g  C o n f i r m a t i o n was  description constitutes  Throughout the and  d i s t r e s s and  the  As  researcher's  the e s s e n t i a l patient.  p a r t i c i p a n t s ' accounts dissonance i s the The  or i n t e r p e r s o n a l  dissonance i n the  discord results in  form of personal  subsequent attempts to reduce the dissonance  d i s t a n c i n g and/or d e s i g n a t i n g  another as the  target  of  care.  Personal dissonance occurs i n one areas.  description.  care to the b r a i n dead  u n i f y i n g theme.  e i t h e r personal  for  then sought from  participants substantiating  s t r u c t u r e of p r o v i d i n g  the  themes r e s u l t e d  p a r t i c i p a n t s as to the accuracy of the  nursing  researcher  in-depth comparative a n a l y s i s of  i n an exhaustive d e s c r i p t i o n of the  pervasive  interactive  meaning u n i t s which were organized i n t o c l u s t e r s  of themes.  the  cared  to f i v e b r a i n dead p a t i e n t s , four nurses  p a r t i c i p a n t s were interviewed  the  nurse had  care f o r s i x to ten b r a i n dead p a t i e n t s , and  nurses had  third  One  or more of  five  These r e l a t e to the p a r t i c i p a n t ' s philosophy about  by  ICU  N u r s e s and  the  Brain  Dead  Patient  161 nursing, concept  to of  traditional brain  transplantation, the  nurse's  dissonance  using  professional  terms s u c h as being  existence  reduce  to  of  subjective  drained, The  and  the  tension  or  contrast, and  own  the  this  amount of  o f f " , being personal  and  interpersonal  families,  nursing  colleagues.  interpersonal  which  the  and  dissonance  participants  frustrated, feeling rotten,  "pissed of  her  to  responsibilities  In  nurse  personal  activities,  retrieval  needs.  PORT Team and  presence  produces  to organ  emotional  the  care  death,  o c c u r s between the  physicians, The  own  nursing  annoyed  and  describe  being  very  being  afraid.  d i s t r e s s r e s u l t s i n a need  d i s s o n a n c e which  the  to  participant is  experiencing. The  dissonance  designation The  former  may  patient  or  latter,  the  by  as  transplant  distancing  a third  party  involve  e i t h e r emotional  a depersonalization  activities.  rationale  of  i s reduced  patient  no  Instead,  longer the  r e c i p i e n t or for providing  the  of  target  the  i s the  patient's  even  the  or  of  the  nursing  detachment  patient.  care.  from  In  the  the  reason  for  nursing  family,  the  unknown  n u r s e h e r s e l f becomes  the  care. Conclusions  The  findings  literature emotionally directly  that  this  caring  laden  related  of  f o r the  process. to  two  study  confirm brain  This  sources  the  dead  personal of  view i n  patient  the  is  an  distress is  inconsistencies.  First,  ICU Nurses and the Brain Dead Patient 162 the nurse may possess coexisting beliefs, perceptions, values, opinions, knowledge and actions which are discrepant.  Second, the nurse's personal values, knowledge,  and behaviours may be in direct opposition to those of her nursing and medical colleagues and those of the family. However, no matter what the source of the dissonance, its existence creates turmoil and makes the care of the brain dead patient and the patient's family challenging. Implications for Nursing The findings of this study have implications for nursing in the areas of practice, education and research. Implications for Nursing Practice The findings of this study lead to a number of important implications for nursing practice.  These are  significant not only for the nurses who provide the care to the brain dead patient but also to nursing and hospital administrators, professional associations, and transplantation programs. The need to care for the nurse is recognized in the literature (Beland, 1979; Muldary, 1983; Pines et a l . , 1981) and is a finding of this study.  The cognitive and  interpersonal dissonance the intensive care unit nurse experiences makes the care of the brain dead patient extremely difficult.  Her only support comes from within  herself and her colleagues, however, even this support may be difficult if she is feeling at odds with herself or with  ICU  N u r s e s and t h e B r a i n  Dead  Patient  163 her  colleagues.  One i m p l i c a t i o n o f t h i s  h o s p i t a l s and p r o f e s s i o n a l a s s o c i a t i o n s to t h i s  to give  recognition  need.  Within a clinical  the h o s p i t a l there nurse s p e c i a l i s t  n u r s e who i s p r o v i d i n g For  study i s f o r  this  specialist  could  be t h e e s t a b l i s h m e n t o f  (CNS) p o s i t i o n t o a s s i s t t h e  t h e c a r e t o t h e b r a i n dead  to f u l l y  patient.  comprehend t h e n e e d s o f t h e  i n t e n s i v e c a r e u n i t n u r s e , s h e must have p r i o r e x p e r i e n c e i n caring  f o r t h e b r a i n dead p a t i e n t  counselling  and f a m i l y .  Expertise i n  and c o m m u n i c a t i o n s k i l l s w o u l d be a n o t h e r  requirement.  To p r o m o t e i n t e r p e r s o n a l  r e l a t i o n s h i p s the  p o s i t i o n w o u l d have t o be c l o s e l y l i n k e d n o t o n l y i n t e n s i v e care u n i t , but a l s o transplantation patient  with  program.  nursing  administration  When a b r a i n  w o u l d be n o t i f i e d . providing  nurse.  nurse  She w o u l d t h e n meet w i t h  specialist t h e n u r s e who  t h e c a r e and s e e k h e r d i r e c t i o n f r o m  w h e t h e r i t be h e l p  p a t i e n t , help a need t o t a l k  hospital  or a  that  T h a t i s , t h e c a r e g i v e r w o u l d i n d i c a t e what h e r  needs a r e ,  The  dead p a t i e n t  and t h e  t h e p o t e n t i a l o f b e i n g b r a i n dead i s a d m i t t e d  to t h e i n t e n s i v e care u n i t t h e c l i n i c a l  is  tothe  with  supporting  with  the p h y s i c a l care of the  the family,  or simply  or take a break or nothing  at a l l .  need f o r s u c h a p o s i t i o n i s a p p a r e n t . systems there  are nursing  meeting  Within the  p o s i t i o n s , such as t h e  N e p h r o l o g y CNS o r t h e T r a n s p l a n t CNS, who f o c u s on t h e n e e d s of  t h e r e c i p i e n t and h i s f a m i l y .  I n a d d i t i o n , PORT p r o v i d e s  ICU  N u r s e s and  the  Brain  Dead  Patient 164  coordinators deal the to  with  to  the  needs of the  needs of the  and  the  brain  intensive  personal that  r e t r i e v e o r g a n s and  care  recipient  dead unit  patient  interpersonal skewed  n u r s e , whether  she  i s caring  will  link  in this The  of  not  be  spectrum  provincial  meeting  an  the  to  nursing  needs of  statements organ by  of on  British organ  retrieval  hospitals  brain  dead  and  and  transplantation the  existence  with of  or  without  1985).  nurses  The  experience  nondonor b r a i n The  do  dead  call  with  result end  is and  patient  must  the  the  the  who  but  the  vital  emphasis  that  These  only  ways  the Nurses  position  success  patients.  this  at  Registered  programs a r e  and  look  is  I t must be  on  recognized though  of  solid  not  a small 1986,  study  reveal  the organ  pivotal  patients  (West  d i s s o n a n c e when c a r i n g  to  exist  percentage  Youngner that  f o r donor  et  the and  patients.  p o s i t i o n statements  associations  to  these  of  dead  associations  become d o n o r s  findings  The  (1988) have  transplantation.  transplantation  them a c t u a l l y  al.,  Columbia  dead  left  labouring  Though b o t h  (1987) and  transplantation,  brain  be  is  death.  associations  is central  family  i s a forgotten  these nurses.  programs,  of  may  to  Meeting  transplantation  donor,  professional  patient  family. his  for a brain  brain  Canadian Nurses A s s o c i a t i o n Association  the  organ of  and  coordinators  incongruities.  are  or  and  n u r s e s who  resources  will  other  for health  of  the  care  national  facilities  and to  provincial provide  ICU  N u r s e s and t h e B r a i n  Dead  Patient 165  support  programs f o r n u r s e s .  associations kind up  should  of support  to a d d r e s s Another  to  play  an a c t i v e  programs n e e d e d .  this  r o l e i n d e t e r m i n i n g the A task  of the study's  e s t a b l i s h m u l t i d i s c i p l i n a r y forums between n u r s e s ,  T h e s e forums s h o u l d values,  opinions  understanding  promote  be s e t  physicians  t o improve  efforts  and t h e PORT Team.  exchange o f b e l i e f s ,  reviews  t o promote  increased  of p a t i e n t  dead  could  turmoil  patient  then  nurses  o f view  cases at  and t h e PORT Team c o u l d  and e x t e r n a l  f o r the b r a i n  i s a need  o f a l l members' p o i n t s  Through  aware o f t h e i n t e r n a l  Collaborative  could  findings  and knowledge i n o r d e r  responsibilities.  when c a r i n g  force  physicians  the f r e e  and r e c o g n i t i o n  these meetings,  professional  issue.  implication  communication  and  However, t h e s e  become experience  and h i s f a m i l y .  be i n i t i a t e d  to r e s o l v e the  conflicts. The  findings  experiences related  family.  members.  This  ethical,  study  also  and e x t e r n a l  p r a c t i c e which  emphasizing related  internal  to the concept  patient's nursing  of t h i s  of death, leads  reveal  discord  with  the nurse  issues  and i n t e r a c t i o n s w i t h t h e  to another  i s the p r o v i s i o n  philosophical  t o d e a t h and a l s o  that  implication for of seminars  and b i o m e d i c a l  the c o u n s e l l i n g  issues  of bereaved  family  ICU  N u r s e s and t h e B r a i n Dead P a t i e n t 166  Implications The  f o r Nursing  findings  of the study  nursing  education.  nursing  should  their  care  prepare  nurses  i s being  to r e c o g n i z e  the source  knowledgeable about education  Additionally,  and  care  The discord  situations  should  of other  I t i s important  of the d i s s o n a n c e  f o r nurses  interventions.  Therefore,  for conflict  resolution.  should  be  among  multidisciplinary  f o r d i s c u s s i o n of h e a l t h care  w i t h i n the h e a l t h care of t h i s  those  i n c l u d e s e s s i o n s on i n t e r p e r s o n a l  providers there  some n u r s e s  health  and t o be  t o promote a g r e a t e r u n d e r s t a n d i n g  results  within  where  n u r s i n g c o l l e a g u e s , o r even  effective  which a l l o w  roles  to handle  provided.  d y n a m i c s and s t r a t e g i e s  sessions  i s that education  may be i n o p p o s i t i o n t o t h o s e  to whom c a r e  health  contain implications f o r  v a l u e s , o p i n i o n s , knowledge or  providers, including  nursing  also  One i m p l i c a t i o n  personal b e l i e f s ,  behaviours  Education  study  experience  issues  system.  provide  evidence  i s related  surrounding  the p r o l o n g i n g of v i t a l  performance  of cardiopulmonary  that the  to i s s u e s  f u n c t i o n s , the  resuscitation  on a dead  patient  and o r g a n  transplantation.  ethical  i n nature  and demand a g r e a t e r a w a r e n e s s o f e t h i c s  by  nurses.  on  these  Education  specific  problems.  regarding ethics  i s s u e s but p r o v i d e  framework f o r v i e w i n g  These dilemmas a r e  and r e s o l v i n g  should  the nurse  focus not only with a  f o r themselves  ethical  ICU  N u r s e s and  the  Brain  Dead  Patient 167  The  study's  surrounding  the  management of major need  of  the  for strong  brain death  give  dead  and  the  their  of  death.  synonymous.  but  also  of  the  preparation the  those  members.  for  nurse  i n the  recognize  health  d i s t r e s s and  but  also  i s required support  for  within  units  sessions  on  dead  patient.  brain  only  inappropriate  the  the  legal  question  practice  for  and  need  be  reactions  of  to  and  the  f o r support  not  Accordingly,  education  to  assist  families.  to  nurses  incorporate  T h e s e programs must  biomedical  care  and  provided  issues  of  o f what i s a p p r o p r i a t e the  death  legal  i n s e r v i c e programs f o r  care  and  professionals  need  as  the  appreciation  own  nurse.  well  in intensive the  the  nursing  h e r s e l f as  o r i e n t a t i o n and  also  care  the  employed  a d d r e s s not  their  of  that  religious,  T h e r e must e x i s t r e c o g n i t i o n  family  to  only  a  meaning  s t u d e n t s must  not  other  Therefore,  They need an  Nursing  of  personal  Hospital  d e a t h but  to  the  recognition  from a p h i l o s o p h i c a l , e t h i c a l ,  legitimacy only  i s the  N u r s e s need  perspective.  confusion  d e a t h and  preparation  w i t h a framework f o r v i e w i n g  family  of  of  families.  findings  educational  death are  biomedical  death  evidence  conceptualization  i m p l i c a t i o n of  significance and  findings  of  the  brain  brain and  dead  patient. Nursing  education  can  provide  the  can  then  apply  be  within  nurse with to  her  the  schools  and  the  hospitals  a t h e o r e t i c a l framework w h i c h  nursing  care  of  the  brain  dead  she  ICU  N u r s e s and  the  Brain  Dead  Patient 168  patient better  and  his  family.  prepared  dissonance  Through  to manage the  associated  with  education  personal  caring  for  the  and the  nurse  can  be  interpersonal brain  dead  patient. Implications  f o r Nursing  A number from  the  involved large  for nursing  this  study.  intensive  unit  n u r s e s who  care  metropolitan  patient  i f their  of  for  with  the  caring  experience  hospitals.  Second,  involved there  respect  perspective  pediatric intensive  essential structure  maintaining operating donor.  a brain  Further  a more g l o b a l  to  brain  nursing In  dead  dead  research picture  patients  practice  and  addition,  interpersonal not  of  the  the  of  the  at  one  care  of  three  brain  have f u r t h e r  work of  dead of  subjective nurses.  of  the  Third,  nurses  reflect brain  the  of  meaning  dead  a r e a s would  experience  dead  participants  care unit  not  two to  n u r s e s who  the  the  of  brain  exists a lack  may  i n these  and  organ  result  providing  implications  care  for  education. study's  dissonance  functioning  to  study  the  of  experience  patient  arise  i s a need  adult  understanding  room n u r s e s a t t a c h  in  is  to  with  still  knowledge w i t h  the  worked  experience  Consequently,  of  the  there  were p r i m a r i l y  patients.  First,  therefore  community  study  research  hospitals,  i s consistent  smaller  this  implications  l i m i t a t i o n s of  determine  in  of  Research  serve  findings as  in isolation.  related  a reminder She  to  that  the  nurse  i s i n t e r a c t i n g with  ICU  N u r s e s and t h e B r a i n Dead  Patient 169  other  nursing  transplant care  u n i t , these  1986,  p h y s i c i a n s , members o f t h e  team and f a m i l i e s .  behaviours  this  colleagues,  that  p. 1 4 5 ) . subculture  Thus w i t h i n  i n d i v i d u a l s f o r m a s u b c u l t u r a l group are "context Research could  r e l a t e d " (Munhall  designed  provide  to study  valuable  b r a i n dead Finally,  in  relation  provision nursing  not  the e x i s t e n c e  to the nurse's  only  of p e r s o n a l philosophy  t o a dead  t h e o r i s t s as they  attempt  i n caring for  dissonance  of nursing  to d e f i n e  a theory  the involvement  be i n c o m p l e t e  experienced  role  on t h e  occurring  and t h e  p a t i e n t has i m p l i c a t i o n s f o r  In today's world  consideration  the dynamics of  patient.  of care  function.  with  & Oiler,  information  phenomenon o f b r a i n d e a t h and n u r s i n g ' s the  the i n t e n s i v e  that  nursing's  does n o t t a k e  of nurses with  but w i l l  unique  contribute  t h e dead  to the  into  will  dissonance  a t the bedside. Summary  This  phenomenological  determine  from  the p e r s p e c t i v e  attached  to c a r i n g  indicate  that  of  dissonance,  subsequent and/or From  research  study  sought to  of the nurse  f o r t h e b r a i n dead  patient.  t h e u n i f y i n g theme f o r t h i s which  attempts  delegating  results to reduce  another  i n personal  and r e s e a r c h  was one  d i s t r e s s and  the dissonance  as t h e r e c i p i e n t  are derived.  The f i n d i n g s  experience  the f i n d i n g s i m p l i c a t i o n s f o r n u r s i n g  education  t h e meaning  by d i s t a n c i n g  of n u r s i n g practice,  The f i n d i n g s and  care.  ICU  N u r s e s and  the  Brain  Dead  Patient 170  implications  are  provide  to  care  administrators, Even  the  brain  of  our  has  brain  health  patient's  major  philosophy  of  other  n u r s e who may  brain  in biomedical  to  dead  may  for  our  but  be  also  to  our  involved  from  patient  technology.  and  n u r s e s who  actually nurse  nurse p r a c t i t i o n e r s .  benefit  ramifications nursing  only  patient  and  family the  not  dead  educators,  conclusion,  advances  patient  the  community  dead In  significant  The  these  is a  nursing  the  findings.  by-product  existence  concept  with  of  practice.  of  this  death,  ICU  Nurses  and t h e B r a i n  Dead  Patient 171  References Ad  Hoc Committee  of the Harvard  the D e f i n i t i o n irreversible Alexander,  M.  premature Center  of B r a i n  coma. JAMA, (1980).  burial  Report,  Anderson,  Medical School  Death.  (1968).  205(6),  The r i g i d  embrace o f t h e narrow  house:  and t h e s i g n s o f d e a t h . The H a s t i n g s  10, 25 - 31.  (Ed.),  Contemporary  A d e f i n i t i o n of  85 - 88.  J . ( 1 9 8 9 ) . The p h e n o m e n o l o g i c a l  M. Morse  t o Examine  Qualitative  Dialogue  Nursing  p e r s p e c t i v e . In J .  Research  A  ( p p . 15 - 2 6 ) . R o c k v i l l e :  An Aspen  Publication. Arnold,  J . D., Zimmerman, T. F., & M a r t i n , D. C ,  Public of  attitudes  the American  Aronson, current  (1968).  and t h e d i a g n o s i s o f d e a t h . The J o u r n a l Medical Association,  E., (1969).  206(9),  The t h e o r y o f c o g n i t i v e  p e r s p e c t i v e . Advances  1949 - 1954.  dissonance: A  i n Experimental  Social  r  Psychology,  _,  2 -  A r o s k a r , M. A., interface  34.  (1981).  of p o l i t i c s  Lipson,  & D. L . Ganos  Medical  Ethics  When d o c t o r and n u r s e and e t h i c s .  d i s a g r e e : An  I n M. D. B a s s o n ,  R. E.  ( E d s . ) . T r o u b l i n g Problems i n  ( p p . 187 - 1 9 2 ) . New  York:  A l a n R.  Liss,  Inc. A r o s k a r , M. A., ( 1 9 8 5 ) . E t h i c a l and  physicians:  perspective.  Goals  relationships  and r e a l i t i e s  I n A. H. B i s h o p  between  nurses  - a nursing  & J . R. S c u d d e r  (Eds).  Caring  ICU  N u r s e s and  the  Brain  Dead  Patient 172  Curing 44  C o p i n g : Nurse P h y s i c i a n  - 61).  Avis,  W.  The  S.,  Bart,  K.  U n i v e r s i t y o f Alabama  (Ed.),  Dictionary.  Toronto: Fitzhenry  to  the  Relationships  & Whitside  J . , & Humphries, A.  shortage  of  cadaveric  transplantation. Transplantation  (pp.  Press.  ( 1 9 8 6 ) . Funk & W a g n a l l s C a n a d i a n  J . , Macon, E.  response  Patient  College  Limited. L.,  (1979). A  kidneys  for  Proceedings,  11,  455  -  458. Bartucci, donor  M.  R.,  family  1 9 ( 6 ) . 305 Bartucci,  responses  perspective.  -  M.  ( 1 9 8 7 ) . Organ d o n a t i o n :  A.  R.,  & Seller,  to k i d n e y  I . L.,  and  (Ed.).  189  P.  letters 18(3),  of  Nursing,  401  -  405.  syndrome i n n u r s e s .  Manifestations - 213).  family  thanks.  G r i e f Responses to  Disability: (pp.  ( 1 9 8 6 ) . Donor  burnout  and  In  Long-Term Nursing  Reston: Reston  and  & W r u b e l , J . , ( 1 9 8 9 ) . The Coping  i n Health  Addison-Wesley P u b l i s h i n g Black,  of N e u r o s c i e n c e  the  Publishing  Inc.  B e n n e r , P., Stress  C,  recipient  ( 1 9 7 9 ) . The  Interventions Company,  M.  Proceedings,  Werner-Beland  Illness  of  309.  Transplantation Beland,  Journal  a study  M.  & Zervas,  N.  death i n n e u r o s u r g i c a l Neurosurgery,  15.(2),  Illness.  of  Menlo  Caring: Park:  Company.  T., and  170  and  Primacy  -  (1984). D e c l a r a t i o n  of  neurological practice. 174.  brain  J.  ICU  Nurses  and  the B r a i n  Dead  Patient 173  Borozny,  M.  issues. Brent,  (1988). B r a i n  Axon,  N.  1 0 ( 2 ) , 37  death: -  Bunch, B.,  N u r s i n g , 1_5(5), 265  & Zahra,  unlearned  role.  D.,  and  J o u r n a l of -  267.  (1976). D e a l i n g with death:  American  moral  d e t e r m i n a t i o n of death a c t :  for nursing practice.  Neurosurgical  religious  41.  J . , (1983). Uniform  implications  legal,  The  J o u r n a l o f N u r s i n g , 7_6(9), 1486  -  1488. B u t c h e r , P.  H.,  ( 1 9 7 9 ) . Management  patients  with brain  death.  Clinics,  H(2),  -  Canadian  Congress  Guidelines of  327  of Death.  Association Medical  role  Nurses  E.,  In R.  Supportive Chapelsky, disagree.  D.,  Canadian  99,  1266  tissue  Nurse,  (1976). Coping  E. C a u g h i l l  Boston:  D.  Basson,  R.  the  Medical Canadian  1267. statement  on  the  donation, r e t r i e v a l 14.  with death  (Ed.),  on  1968.  -  84(3),  The  Little,  (1981) I n t r o d u c t i o n :  In M.  (Draft Version  Committee  ( 1 9 8 8 ) . CNA  and  Canadian  Approach,  death  d e a t h , November  Journal,  i n organ  transplantation.  units.  on  Association,  of n u r s e s  R.  Special  ( 1 9 6 8 ) . The  statement  Association  Caughill,  S c i e n c e s . (1986).  unpublished.  Medical Association  Definition  Canadian  332.  f o r the d i a g n o s i s o f b r a i n 1986,  of  International Anesthesiology  of N e u r o l o g i c a l  28 F e b r u a r y ,  Canadian  o f the r e l a t i v e s  Dying  i n acute  care  Patient:  Brown and  Company.  When d o c t o r and  E. L i p s o n , & D.  A  L.  nurse Ganos,  and  ICU  Nurses  and  the B r a i n  Dead  Patient 174  ( E d s ) . T r o u b l i n g Problems i n M e d i c a l E t h i c s 182).  New  York:  Christopherson, transplant  L. K.,  donors  Psychiatry, Conboy-Hill, care:  A l a n R.  and  of M e d i c a l R o y a l  1069  -  Cooper, J . , (1971). The  role  and  Social  theory.  Press,  Inc.  1187  -  Faculties  in  death.  1188.  C o l l e g e s and  their  Faculties  D i a g n o s i s of b r a i n  R.  1_8(3), 354 H.,  17  -  (1984).  (Ed.).  ( p p . 229  C o o p e r , J . , & G o e t h a l s , G.  R.,  the e l i m i n a t i o n  of c o g n i t i v e  Personality  Social  and  their  Personal r e s p o n s i b i l i t y  In L. B e r k o w i t z Psychology,  Nursing  in  death.  1070.  Psychology  Social  and  D i a g n o s i s of b r a i n  of f o r e s e e n consequences.  Cooper, J . , & F a z i o ,  in  International  C o l l e g e s and  the U n i t e d Kingdom. ( 1 9 7 6 b ) . 2,  Seminars  of n u r s e s ' a t t i t u d e s  2,  Medical Journal,  Lancet,  Heart  21.  of M e d i c a l R o y a l  Conference  (1971).  P s y c h o s o c i a l a s p e c t s of t e r m i n a l  the U n i t e d Kingdom. ( 1 9 7 6 a ) . British  -  35.  study  19 -  T.,  families.  i n a general hospital.  Review, 3 3 ( 1 ) , Conference  -  (1986).  A preliminary  behaviour  their  179  Inc.  & Lunde, D.  3 ( 1 ) , 26 S.,  Liss,  (pp.  and  dissonance:  J o u r n a l of  Personality  363. A new  Advances - 266).  look at  dissonance  i n Experimental Orlando:  (1974). Unforeseen  Academic  events  d i s s o n a n c e . J o u r n a l of  Psychology.  2j)(4), 441  -  445.  and  ICU  Nurses  and  the B r a i n  Dead  Patient 175  Cooper,  J . , & Worchel,  S.,  (1970). Role  consequence  in arousing cognitive  Personality  and  Couch, N.  P.,  Social  J . , Hyg,  use  New  J o u r n a l of M e d i c i n e ,  Cowles,  K.  V.,  Outlook. Cushing,  of cadaver  (1984). L i f e ,  32,(3), 168  H.  -  tissue  death  t e n s i o n . The  American  D a l y , K.  -  in transplantation. 271, and  691  J o u r n a l of  d i a g n o s i s of b r a i n  Darby, J . M.,  Stein,  J . , ( 1 9 8 9 ) . How  M.,  and  Nursing, Davitz,  J o u r n a l of  89. Stuart,  M.,  responsibilities. 1 9 ( 1 ) , 36  1510.  define  N u r s i n g Review. 3_6(3),  -  S.  A.,  suffer.  (1989) dead'  ethical  dilemmas.  87.  (1987). B r a i n J o u r n a l of  death: nursing  Neuroscience  39.  L. J . , & D a v i t z ,  -  -  of  2222 - 2228.  nurses  & Lemke, D.  when p a t i e n t s 1505  85  G r e n v i k , A.,  JAMA, _261(15),  International  roles  K.,  ,  overview  to management o f the h e a r t b e a t i n g ' b r a i n  donor.  K.  Nursing  intracranial  death:  N u r s i n g , 1_(2)  Davis,  695.  the M e d i c a l S c i e n c e s ,  Neurosurgical  A.  The  clinical  of i n c r e a s e d  nursing r e s p o n s i b i l i t i e s .  Davis,  -  personhood.  neurosurgical  organ  D.  400.  ( 1 9 8 2 ) . The  Approach  206.  & Moore, F.  ( 1 9 0 2 ) . Some e x p e r i m e n t a l and concerning status  375  -  172.  observations  124,  16.(2), 199  S. M.,  ( 1 9 6 4 ) . The England  d i s s o n a n c e . J o u r n a l of  Psychology.  C u r r a n , W.  of u n d e s i r e d  J . R., American  ( 1 9 7 5 ) . How  do  nurses  feel  J o u r n a l o f N u r s i n g , 75(9) ,  ICU  Nurses  and  the B r a i n  Dead  Patient 176  Elkin,  R.  A.,  arousal,  & L e i p p e , M.  d i s s o n a n c e , and  dissonance-arousal Journal  R.,  link  of P e r s o n a l i t y  (1986). P h y s i o l o g i c a l  a t t i t u d e change: E v i d e n c e and  and  a "don't  remind  me"  S o c i a l Psychology,  for a  effect.  5_1( 1) , 55  -  65. Fabro,  F.  ( 1 9 8 2 ) . To  Medicine, Field,  P.  306,  A.,  .Application Publishers, Festinger,  Festinger,  Journal  (1957). A Theory  Stanford L.,  A.,  of C o g n i t i v e  University  & Carlsmith, of f o r c e d 58,  In A. H.  Caring  Curing  Relationships  (1959).  compliance. 203  -  Dissonance,  Press.  J . M.,  Cognitive  Journal  of  Abnormal  211.  ( 1 9 8 5 ) . Nurse and  relationship.  Bishop  p a t i e n t : The  caring  & J . R.  Scudder  Coping:  Nurse P h y s i c i a n  Patient  ( p p . 31  - 4 3 ) . The  University  (Eds.).  of  Alabama  Press. Gideon, care  M.  D.,  & Taylor,  of the cadaver  Neurosurgical Giorgi,  A.  of  P.  B.,  donor's  (1981). Kidney  family.  N u r s i n g , 1 3 ( 5 ) , 248  (1975a).  An  method  i n psychology.  Murray  (Eds.).  -  a p p l i c a t i o n of In A.  Journal  Duquesne S t u d i e s  in  donation: of  251. phenomenological  G i o r g i , C.  The  R o c k v i l l e : Aspen  Inc.  Psychology,  Gadow, S.  England  (1985), Nursing Research:  of Q u a l i t a t i v e Approaches,  consequences Social  New  1361.  & M o r s e , J . M.,  L.  Stanford:  the e d i t o r . The  Fischer,  &  E.  Phenomenological  ICU  N u r s e s and  the  Brain  Dead  Patient 177  Psychology  ( V o l . 2,  University  Press.  Giorgi,  A.  in  C.  and  Fischer,  Pittsburgh: G.  R.,  dissonance.  & E.  the  and  Murray  Psychology  & Cooper, J . , consequence  Journal  293  Goldsmith  103).  -  Pittsburgh:  divergence  (Eds.). ( V o l . 2,  Duquesne U n i v e r s i t y  postbehavioral  23(3).  -  Duquesne  of  q u a n t i t a t i v e methods i n p s y c h o l o g y .  Phenomenological  Goethals,  82  (1975b). Convergence  qualitative Giorgi,  pp.  of  In  A.  Duquesne  Studies  pp.  79).  72  -  Press.  (1972). Role  i n the  arousal  Personality  and  of  intention  of  cognitive  and  S o c i a l Psychology,  301.  J . , & Montefusco,  p o t e n t i a l organ  C.  M.,  (1985). Nursing  donor. C r i t i c a l  care  of  C a r e N u r s e . _5(6),  22  29. G r e e n , M.  B.  identity. Greenwald,  Hay,  D.,  Health  (1980). B r a i n  Philosophy  and  Public  Affairs,  D.  ( 1 9 7 8 ) . Twenty  G.,  & Ronis,  dissonance:  Psychological & Oken, D.,  Intensive 34.(2),  D.,  A.  cognitive theory.  & Wikler,  Care  109  -  of  study  of  the  Review, 8J5(1) . 53  ( 1 9 7 2 ) . The  unit Nursing.  and  9/2),  105  -  years  evolution -  personal  of  133. of a  57.  psychological  Psychosomatic  Stresses  of  Medicine.  118.  Services  diagnosis  Case  L.,  death  Directorate, brain  death.  (1986). G u i d e l i n e s Organ and  Services  in Hospitals: Guidelines  Minister  of  Supply  and  Services  Tissue  (pp.  Canada.  70  for  the  Donation -  76),  Ottawa:  -  ICU  Nurses  and  t h e . B r a i n Dead  Patient 178  Henderson, in  V.  A.,  ( 1 9 8 0 ) . P r e s e r v i n g the e s s e n c e  a technological  245  -  J o u r n a l o f Advanced  & Lewandowski, L.,  with f a m i l i e s :  17.(6). 670  -  (1988). C r i t i c a l  A descriptive  health  c a r e . In J . Howard & A.  Humanizating Wiley  &  study. Heart  and  Lung,  H e a l t h Care  and  dehumanization  Strauss  of  (Eds.).  ( p p . 57 - 1 0 2 ) .  New  York:  John  Sons.  I v a n , L. P.  (1973).  Neurology, Johnstone,  23,  M.  Spinal  650  -  reflexes  J . , ( 1 9 8 9 ) . Law,  of c o n f l i c t  Nursing  Review. 3 6 ( 3 ) , 83 -  Kaufman, H.  H.,  Neurosurgery, R.  C.  Knaack, P. Journal  professional  J . , (1986). B r a i n  19.(5), 850  ( 1 9 8 2 ) . To  -  maintenance  the e d i t o r .  death.  The  New  England J o u r n a l  6/1),  organ  donor.  r e s e a r c h . Western 107  -  114.  in identification  Heart  and  Lung,  1_7(4).  371.  Lamb, D.  (1985). Death,  Croom Helm.  the  1362.  ( 1 9 8 8 ) . Case s t u d y  o f an  and  856.  (1984). Phenomenological  L. M.,  ethics  89.  of N u r s i n g Research,  Kozlowski,  death.  with personal values. I n t e r n a t i o n a l  & Lynn,  of M e d i c i n e , 306,  in cerebral  652.  problem  -  care nurses'  676.  Howard, J . , ( 1 9 7 2 ) . H u m a n i z a t i o n  Klein,  N u r s i n g , _5,  260.  H i c k e y , M., role  age.  of n u r s i n g  Brain  Death  and  Ethics.  London:  and 366  ICU  Nurses  and  the B r a i n  Dead  Patient 179  Larson,  D.  G.,  secrets. Law  Reform C o m m i s s i o n  of  Internal  stressors  o f Canada. ( 1 9 7 9 ) . W o r k i n g P a p e r  f o r the D e t e r m i n a t i o n o f D e a t h .  Supply  and  Services  Reform C o m m i s s i o n  o f Canada.  (1981). Report  the D e t e r m i n a t i o n o f D e a t h .  and  Services N.  Journal 25(3),  & Lederach,  Cognitive  Leininger,  32  M.  Minister  15:  Ottawa: M i n i s t e r  -  M.,  health.  In M.  Nursing  and  M.  J . P.,  dissonance  of p s y c h o s o c i a l pp.  23:  Criteria of  Supply  Canada.  K.,  psychiatry:  Ottawa:  27.  Canada.  for  Lederach,  i n nursing: Helper  J o u r n a l of P s y c h o s o c i a l N u r s i n g , 2_5(4), 20 -  Criteria  Law  (1987).  (1987). R e l i g i o n  and  in nursing students.  n u r s i n g and  mental  health  services  36. (1984). Care: Leininger  the e s s e n c e  (Ed.).  o f n u r s i n g and  C a r e : The  Essence  of  H e a l t h (pp. 3 - 15). T h o r o f a r e : S l a c k  Incorporated. Leininger,  M.  (1985). Nature,  qualitative Leininger  (Ed.). Qualitative  Lippincott,  Lofland,  R.  C,  Research  and  O b s e r v a t i o n and Company,  Inc.  stress  Settings:  Analysis.  of  M.  Inc.  Lung, 8_,(6), 1093  J . , (1971). A n a l y z i n g S o c i a l  Publishing  importance  Methods i n N u r s i n g  Grune & S t r a t t o n  (1979). P s y c h o l o g i c a l  making. H e a r t  Qualitative  and  r e s e a r c h methods i n n u r s i n g . In M.  (pp. 1 - 25). Orlando:  decision  rationale,  factors -  in  1097. A Guide  to  B e l m o n t : Wadsworth  ICU  Nurses  and  the B r a i n  Dead  Patient 180  Lynch-Sauer, method  J . , (1985). Using a phenomenological  to study n u r s i n g  (Ed.). Qualitative  phenomena. In M.  A.  S.,  & Petrucelli,  Illustrated Harry  History  P.,  R.  - 438,  Health  ( 1 9 8 2 ) . Death  In J . Q.  Publishing Mechanic,  York: Morse,  1711  ( E d . ) . Death  ( p p . 51  -  1713. nursing  E d u c a t i o n f o r the  - 65). Washington:  (1972). I n t r o d u c t i o n .  ( E d s ) . Humanizing  John W i l e y & J . M.,  issues  291,  Hemisphere  Corporation.  D.,  Strauss  York:  c a r e o f the  e d u c a t i o n f o r advanced  Benoliel  Professional  - 5 1 2 ) . New  to p s y c h o l o g i c a l  dying. B r i t i s h Medical Journal,  practice.  510  An  Publishers.  (1985). B a r r i e r s  M c C o r k l e , R.,  -  Inc.  J . (1987). Medicine  ( p p . 432  N. Abrams, I n c . ,  Maguire,  Leininger  R e s e a r c h Methods i n N u r s i n g ( p p . 93  1 0 7 ) . O r l a n d o : Grune & S t r a t t o n Lyons,  M.  research  H e a l t h Care  A.  (pp. 1 - 5 ) .  New  Sons.  (1986). Q u a n t i t a t i v e  i n s a m p l i n g . In P.  Methodology  In J . Howard &  ( p p . 181  and  L. C h i n n  qualitative  (Ed.),  - 193). R o c k v i l l e :  research:  Nursing Research  An  Aspen  Publication. Morse,  J . M.  (1989). S t r a t e g i e s  (Ed.). Qualitative Dialogue Morton,  ( p p . 117  J . B.,  nephrectomy:  f o r s a m p l i n g . In J . M.  Morse  Nursing Research A Contemporarily - 131). R o c k v i l l e :  & L e o n a r d , D. an o p e r a t i o n  M e d i c a l J o u r n a l , J^,  239  R. on  A.,  An  (1979).  the donor's  - 241 .  Aspen  Publication.  Cadaver family.  British  ICU  Nurses  and t h e B r a i n  Dead  Patient 181  Muldary,  T. W.,  (1983).  Professionals:  Interpersonal Relations  A Social  Skills  Approach  f o r Health  (pp. v - v i i i ,  - 95, 109, 198- 218, 227 - 228, 247, 251 - 2 7 7 ) . New MacMillan Munhall,  Publishing  67 York:  Co., I n c .  P. L., & O i l e r ,  C. J . , ( 1 9 8 6 ) . Language and n u r s i n g  research.  I n P. L. M u n h a l l  Research:  A Qualitative  & C. J . O i l e r  (Eds.).  Nursing  P e r s p e c t i v e ( p p . 3 - 25, 1 4 5 ) .  Norwalk: A p p l e t o n - C e n t u r y - C r o f t s . Murphy, P. A., ( 1 9 8 6 ) . R e d u c t i o n i n n u r s e s ' d e a t h a n x i e t y following  a d e a t h a w a r e n e s s workshop. The J o u r n a l o f  Continuing Nel,  Education i n Nursing,  E., Helrareich,  R.,  change i n t h e a d v o c a t e of  & Aronson,  ll{h),  E., (1969).  as a f u n c t i o n  h i s audience: A c l a r i f i c a t i o n  115 - 118. Opinion  of the p e r s u a s i b i l i t y  o f t h e meaning o f  dissonance. J o u r n a l of P e r s o n a l i t y  and S o c i a l  Psychology,  1_2(2), 117 - 124. Nightingale,  F., ( 1 8 5 9 ) . N o t e s on N u r s i n g , P h i l a d e l p h i a : J .  B. L i p p i n c o t t Oiler,  Company.  C. ( 1 9 8 6 ) . Phenomenology: t h e Method. In P. L .  Munhall  & C. J . O i l e r  Qualitative  (Eds.). Nursing Research: A  P e r s p e c t i v e ( p p . 69 - 8 4 ) . N o r w a l k :  Appleton-  Century-Crofts. Oiler,  C. ( 1 9 8 2 ) . The p h e n o m e n o l o g i c a l  research. Nursing Research,  31(3),  approach  i n nursing  178 - 181.  Omery, A., ( 1 9 8 3 ) . Phenomenology: a method  for nursing  r e s e a r c h . A d v a n c e s i n N u r s i n g S c i e n c e , _5(2), 49 - 63.  ICU  Nurses  and t h e B r a i n  Dead  Patient 182  Pallis, brain  C. ( 1 9 8 2 ) . ABC o f b r a i n stem  stem  death - I I . B r i t i s h  death - d i a g n o s i s of  Medical Journal,  285, 1641  - 1644. Pallis,  C. ( 1 9 8 8 ) . B r a i n s t e m  concept.  I n P. J . M o r r i s  Principles  and P r a c t i c e  B. S a u n d e r s Parisi,  J . E . , Kim, R. C ,  England  Pacific  Transplantation:  ( p p . 123 - 1 5 0 ) . P h i l a d e l p h i a :  W.  Collins,  G. H. & H i l f i n g e r ,  Journal  somatic  M. F.  survival.  The  o f M e d i c i n e , 306, 14 - 16.  Organ R e t r i e v a l f o r T r a n s p l a n t a t i o n , Vancouver:  Pacific  (1986).  1986  Organ R e t r i e v a l  Transplantation.  Pacific  Organ R e t r i e v a l f o r T r a n s p l a n t a t i o n ,  P.O.R.T. S t a t i s t i c s , for  Vancouver:  Pacific  (1987).  1987  Organ R e t r i e v a l  Transplantation.  Pacific  Organ R e t r i e v a l f o r T r a n s p l a n t a t i o n ,  P.O.R.T. S t a t i s t i c s , for  Vancouver:  Pacific  (1988).  1988  Organ R e t r i e v a l  Transplantation.  Pines,  A. M.,  From Tedium  Aronson,  Stupor  Davis  E., & K a f r y ,  D.,  t o P e r s o n a l Growth. New  Plum, F., & P o s n e r , of  Kidney  death with prolonged  P.0.R.T. S t a t i s t i c s , for  (Ed.).  of a  Company.  (1982). B r a i n New  d e a t h : The e v o l u t i o n  Company.  York:  J . B. ( 1 9 8 0 ) . B r a i n  and Coma,  (1981).  Burnout:  The F r e e  Press.  d e a t h . The D i a g n o s i s  ( p p . 313 - 3 2 4 ) . P h i l a d e l p h i a : F. A.  ICU  Nurses  and t h e B r a i n  Dead  Patient 183  President's Medicine  Commission  and B e h a v i o r a l R e s e a r c h .  Washington, Quint,  f o r t h e Study  J. C ,  J. C ,  problem.  ( 1 9 6 6 ) . Awareness o f D e a t h  Death,  Office.  and t h e N u r s e ' s  L5( 1) , 49 - 55.  ( 1 9 6 7 ) . The d y i n g p a t i e n t :  Nursing C l i n i c s  Problems i n  (1981). D e f i n i n g  DC: U.S. Government P r i n t i n g  Composure. N u r s i n g R e s e a r c h , Quint,  of E t h i c a l  A difficult  of North America,  nursing  2 / 4 ) , 763 -  773. Reisetter, dying:  K. H., & Thomas, B., ( 1 9 8 6 ) . N u r s i n g c a r e o f t h e  Its relationship  International Registered Position donation, 20(4),  to s e l e c t e d  J o u r n a l of N u r s i n g S t u d i e s ,  Nurses  Association  statement: retrieval,  The r o l e  of B r i t i s h of nurses  characteristics. 2_( 1) , 39 - 50.  Columbia.  (1988).  i n organ  and t i s s u e  and t r a n s p l a n t a t i o n .  RNABC News,  pp.27, 28.  Riemen, D. J . , ( 1 9 8 6 ) . The e s s e n t i a l interaction: Oiler  nurse  structure  of a c a r i n g  d o i n g phenomenology. I n P. L. M u n h a l l  (Eds.).  Nursing Research:  & C. J .  A Qualitative Perspective  ( p p . 85 - 1 0 8 ) , N o r w a l k : A p p l e t o n - C e n t u r y - C r o f t s . Roberts,  S. L . , ( 1 9 8 6 ) . D e p e r s o n a l i z a t i o n . B e h a v i o u r a l  Concepts  and t h e C r i t i c a l l y  111 P a t i e n t  (pp276 - 2 9 7 ) .  Norwalk: A p p l e t o n - C e n t u r y - C r o f t s . Ropper, A. ( 1 9 8 4 ) . U n u s u a l dead  patients.  Neurology,  spontaneous  movements i n b r a i n  34, 1089 - 1092.  ICU  Nurses  and  the B r a i n  Dead  Patient 184  Selby, H.  R.  (1985).  W i l k i n s & S.  pp.  T.  (1980).  physician  medical  d e t e r m i n a t i o n of death.  Rengachy New  The  (Eds.),  York:  McGraw-Hill  structure  relations.  Neurosurgery Book  of c o n f l i c t  S u p e r v i s o r Nurse.  In  R.  ( V o l . 3,  Company.  i n nurse-  11/8),  14 - 15,  17  18.  Sinacore, death:  J . M., An  Sophie,  F.  cadaver  Avoiding the  the h u m a n i s t i c  implicit  elements  aspect  of  Salloway,  K.,  (1983).  organ  J. C ,  Sorock,  G.,  of  health  e d u c a t i o n . D e a t h E d u c a t i o n , 5 ( 2 ) , 121  L. R.,  Merkel,  (1981).  outcome from  professions  of  S.  2585 - 2 5 9 7 ) .  Sheard,  -  The  Volek,  -  133.  P.,  &  Intensive care nurses' perceptions  procurement.  Heart  and  Lung, J J 2 ( 3 ) ,  262  -  267. Stehle,  J . L.,  findings Sullivan, organ  revisited. P.  (1988).  Critical Nursing  Report  transplantation.  Journal,  139,  Sweezy, S. in  (1981).  R.,  433  -  care nursing s t r e s s :  Research,  raises  Canadian  (1983).  Ethical  Relationship. Toffler,  A.  The  Travelbee,  Problems  Boston:  (1970).  ethical  Philadelphia:  F.  A.  Medical  186.  cost  of  Association  issue P.  of i n f o r m e d  Murphy  and  Bacon,  Hunter,,  Shock. New  Inc.  York:  I n t e r p e r s o n a l Aspects Davis  & H.  consent  i n the N u r s e - P a t i e n t  Allyn  Future  J . , (1971).  q u e s t i o n s about  -  434.  human e x p e r i m e n t a t i o n . I n C.  (Eds.).  _3_0(3), 182  The  Company.  Random of  House.  Nursing.  ICU  Nurses  and  the B r a i n  Dead  Patient 185  W a l k e r , E. A., cerebral  (1979).  death.  Advances  In R.  A. Thompson & J . R.  Advances i n n e u r o l o g y : system  trauma  W a l k e r , E. A.,  i n the d e t e r m i n a t i o n o f  V o l . 22  (pp.167 - 1 7 7 ) . (1985).  Green  (Eds.),  C o m p l i c a t i o n s of  nervous  New  York:  C e r e b r a l Death,  Raven P r e s s .  B a l t i m o r e : Urban  &  Schwarzenberg. Weber, P., nurse  (1985).  i n organ  17.(2), 119  -  West, J . C , B.,  Wikler, over  transplants.  Youngner, S. Hau,  J.,  (1985).  of  the  E.,  Campbell,  (1986).  A.  P h i l o s o p h y and  J . , (1989).  JAMA,  2_61(15),  M., D.  L.,  England  89,  financing  of  22,26.  Appropriate confusion  2246.  Bartlett,  E. T.,  Mahowals, M.  P s y c h o s o c i a l and New  Burns-Morrison,  Pennsylvania Medicine,  Jackson,  The  P.,  ethical  C a s c o r b i , H. B.,  & Martin,  implications  J o u r n a l of M e d i c i n e ,  of  B.  organ  313(5),  324.  Youngner,  S.  J . , L a n d e f e l d , S.,  & L e a r y , M.  retrieval concepts 2210.  death'.  T.,  retrieval.  B. W.,  A.  J., Allen,  F.,  -  S.  & Weisbard,  'brain  role  122.  Kelley,  D.,  human c o n n e c t i o n : The  d o n a t i o n . J o u r n a l of N e u r o s u r g i c a l N u r s i n g ,  & Zimmerman, K.  organ  321  The  (1989).  A cross-sectional among h e a l t h  C o u l t o n , C.  'Brain survey  death'  J., Juknialis, and  organ  o f knowledge  professionals.  JAMA,  and  261(15),  2205 -  ICU  Nurses  and  the B r a i n  Dead  Patient 186  Appendices  ICU Nurses and the B r a i n Dead P a t i e n t 187  Appendix A C e r t i f i c a t e of Approval f o r the Study  ICU N u r s e s and  t h e B r a i n Dead  Patient 189  Appendix Letter  of  B  Information  ICU  N u r s e s and t h e B r a i n Dead P a t i e n t 190  Letter The  of Information f o r Research  Experiences  of I n t e n s i v e Care U n i t Nurses P r o v i d i n g Care  to I  The A d u l t B r a i n Dead P a t i e n t  am a r e g i s t e r e d  nurse  working  degree i n n u r s i n g a t the U n i v e r s i t y F o r my t h e s i s , understanding  Study:  I am c o n d u c t i n g  towards a of B r i t i s h  a study  of the experience  heightening caring  of i n t e n s i v e care nurses  This l e t t e r  patient.  nurse  i n the i n t e n s i v e  at least  study w i l l  w i t h a minimum o f one y e a r  c a r e u n i t and have p r o v i d e d  involve approximately  will  t i m e and p l a c e .  During  be s c h e d u l e d  the past  at a mutually  year.  convenient be f r e e t o  perspective of c a r i n g f o r the  The i n t e r v i e w s w i l l  i n data c o l l e c t i o n .  care  t h r e e , one h o u r  t h e i n t e r v i e w s you w i l l  comment as you w i s h a b o u t y o u r b r a i n dead p a t i e n t .  i n my  i n the study r e q u i r e s  one b r a i n dead p a t i e n t w i t h i n  i n t e r v i e w s which  accuracy  you t o p a r t i c i p a t e  forparticipation  t h a t you be a r e g i s t e r e d  The  I hope t h e  be v a l u a b l e f o r n u r s i n g by  i s to i n v i t e  s t u d y . The c r i t e r i a  for  who  the awareness about n u r s e s ' e x p e r i e n c e s i n  f o r t h e b r a i n dead  experience  Columbia.  t o g a i n an  p r o v i d e c a r e t o t h e a d u l t b r a i n dead p a t i e n t . f i n d i n g s of the study w i l l  master's  be t a p e d  to ensure  However, COMPLETE  CONFIDENTIALITY WILL BE ENSURED THROUGHOUT THE STUDY by t h e c o d i n g o f d a t a by numbers. The  f i n d i n g s of the study w i l l  f o r u m s and a l s o s u b m i t t e d  be p r e s e n t e d  at nursing  to p r o f e s s i o n a l nursing j o u r n a l s  ICU N u r s e s and  the B r a i n  Dead  Patient 192  Appendix Addendum t o L e t t e r  C of  Information  ICU  N u r s e s and t h e B r a i n  Dead  Patient  193 Addendum t o L e t t e r The E x p e r i e n c e s Care  In all  of Information  of I n t e n s i v e  to the Adult  addition,  p a r t i c i p a n t s throughout  patient  information  interview patients their  will  family  will  before  preceding  time d u r i n g  stop  Providing  Patient  c o n f i d e n t i a l i t y of  the study,  c o n f i d e n t i a l i t y of  be p r o t e c t e d . be a s k e d  members.  f a m i l i e s a r e mentioned  taping  Dead  Nurses  Study:  complete  the p a r t i c i p a n t s w i l l and t h e i r  Care U n i t  Brain  to ensuring  For Research  At t h e s t a r t  of each  n o t t o name  I f names o f p a t i e n t s and  during  the taped  interview,  and t h e names w i l l  be e r a s e d  from  with  the remainder  of the i n t e r v i e w .  will  o r f a m i l i e s be r e f e r r e d  the study  patients  to by name.  Margaret  B o r o z n y , R.N.,  U.B.C. MSN  Student  B.S.N.,  the  the tape At no  ICU N u r s e s and t h e B r a i n Dead  Patient 194  Appendix D C o n s e n t Form  ICU  N u r s e s and t h e B r a i n  Dead  Patient 195  Consent I have r e a d with  intensive  the l e t t e r  care  adult  brain  dead  study  with her.  times  that  convenient.  Borozny's  provide  care  and I have f u r t h e r  Margaret  f o r a maximum  meetings w i l l  about Margaret  n u r s e s who  patient,  I understand three  unit  Form  Borozny w i l l  o f one hour  be a t a p l a c e  each  of c a r i n g  discussed  the  meet w i t h  me  The  i s mutually  The p u r p o s e o f t h e m e e t i n g s w i l l  w i t h me my e x p e r i e n c e  to the  time.  and t i m e w h i c h  study  f o r the a d u l t  be t o d i s c u s s brain  dead  patient. I any  further  understand  of the m a t e r i a l s ,  protected. results  and t h a t  I do u n d e r s t a n d ,  of the study  professional nurses attach  my name w i l l my i d e n t i t y  however,  may be p u b l i s h e d  a w a r e n e s s o f t h e meaning to c a r i n g  I understand recordings  that  that  f o r the b r a i n i f I give  request  erasure  of m a t e r i a l s  outside  of the i n t e r v i e w  I understand  that  that  will  that  be  the o v e r a l l  t o promote intensive dead  I have  care  unit  adult.  permission  made o f t h e i n t e r v i e w s ,  n o t a p p e a r on  t o have  tape  the r i g h t to  I do n o t w i s h  t o be t a k e n  room.  I ALSO HAVE THE RIGHT TO WITHDRAW  FROM THE STUDY AT ANY TIME AND THAT MY WITHDRAWAL WILL IN NO WAY  AFFECT MY EMPLOYMENT.  TO ANSWER ANY QUESTION.  I ALSO HAVE THE RIGHT TO REFUSE  ICU  Nurses  and  the  Brain  Dead  Patient  196 I  hereby  give  my  consent  to  participate in  this  Signed: Witness: Date : I  acknowledge  Signed:  receiving  a  copy  of  this  consent  form.  study.  ICU N u r s e s and  the B r a i n  Dead  Patient 197  Appendix  E  Trigger Questions  ICU  N u r s e s and  the  Brain  Dead  Patient 198  Trigger The  trigger  interview the  were g e n e r a t e d  literature  dissonance 1.  questions  framework.  to  by  r e v i e w and  Questions  the  the  These  What i s i t l i k e  be  used  f o r the  study's  research  Festinger's questions  f o r you  initial question,  cognitive  are:  to care  for a brain  beliefs  affected?  dead  patient? 2.  How  are  3.  How  do  your  your you  values  deal  beliefs  and  and  with your  any  i n c o n s i s t e n c i e s between  responsibilities?  ICU  Nurses  and  the B r a i n  Dead  Patient 199  Appendix  F  Sociodemographic  Data  ICU  N u r s e s and  t h e B r a i n Dead P a t i e n t 200  The  Experiences  of I n t e n s i v e Care U n i t Nurses P r o v i d i n g Care to  t h e A d u l t B r a i n Dead P a t i e n t Demographic  Survey  Code: Age:  20-30  Sex:  Female  31-40  41-50  >51  Male Place  Race:  of  Years i n  Birth: Canada:  Religion; Basic  Nursing  Education: Years:  Hospital  Years:  College University: Post  Graduate  Education:  Program: Place: Program: Place: Nursing  Degrees:  BSN: University:_ MSN: University: Non  Nursing  Degrees:  Degree: University:  Years:  ICU  N u r s e s and t h e B r a i n Dead  Patient 201  Work  Experience: Total  Years  Experience Other  Current  i n I.C.U.:  Areas:  Position:  Position:  Approximate 1  i n Nursing:  Number o f B r a i n Dead 2-5  6-10  P a t i e n t s Cared F o r : >10  

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