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Ethical Decision Making in Critical Care: Communication, Coordination of Care, and the Practice of the Clinical Nurse Specialist.

Experts in critical care recommend early and ongoing discussions between clinicians and patients/families in the intensive care unit (ICU) to explain patient's status, provide prognostic assessments, and explore what the patient and/or surrogate identify as important values and life philosophies that drive medical decision making. In shared decisionmaking, a partnership is established among providers, patients, and their loved ones with the goal of exchanging information and reaching consensus. One in 5 Americans die after receiving care in the ICU; decision making is particularly complex due to the quantity and complexity of data being presented, the rapid change in the course of the patient's condition, and differing expectations regarding prognosis between physicians and surrogate decision makers. This article aims to review some of the challenges that arise with medical decision making for patients and families facing serious illness in the ICU by presenting a simulated case study and highlighting the practice of the clinical nurse specialist (CNS) in the critical care setting. SIMULATED CASE STUDY: Mrs Z. was found down at the office where she worked. She was 58 years old, with 3 young adult children, a partner of 30 years, and large extended family. Mrs Z. suffered a devastating stroke; she was unable to speak for herself when she arrived in the emergency department, and she was subsequently admitted to the ICU on a ventilator. She did not have an advance directive; various family members sat at her bedside around the clock. The intensivist provided daily medical updates