Registered nurses ’ experience of the withdrawal of treatm ent from the critically ill patient in an intensive care unit

In this article the results of research undertaken to ex­ plore and describe the experience of Registered Nurses regarding the withdrawal of treatment from the critically ill patient in an Intensive Care Unit (ICU), are discussed. Withdrawal of treatment from a critically ill patient in an Intensive Care Unit (ICU) is a very traumatic experience for all those involved. The Registered Nurse has the most contact with all those who are involved through­ out the process. This raises questions regarding how the nurse experiences the withdrawal of treatment, and about guidelines that can be developed to accompany the nurse during the process of treatment withdrawal. The study was qualitative, descriptive, exploratory, de­ scriptive and contextual in nature. Data was gathered by means of phenomenological interviews conducted by the researcher. Trustworthiness was ensured through the implementation of Guba’s model (in Krefting 1991: 214). The following themes were identified: 1. The relationships the nurse develops with indi­ viduals involved in the process of treatment withdrawal. 2. The inner moral conflict experienced by the nurse relating to the ethical aspects of withdrawal of treatment. The focus of this article is on the discussion of these experiences of the registered nurses. Based on the iden­ tified themes, guidelines were developed to accompany the nurse during the process of withdrawal of treat­ ment.

The study was qualitative, descriptive, exploratory, de scriptive and contextual in nature.Data was gathered by means of phenomenological interviews conducted by the researcher.Trustworthiness was ensured through the implementation of G uba's model (in Krefting 1991: 214).The following themes were identified: 1.
The relationships the nurse develops with indi viduals involved in the process of treatment withdrawal.

2.
The inner moral conflict experienced by the nurse relating to the ethical aspects of withdrawal of treatment.The focus of this article is on the discussion of these experiences of the registered nurses.Based on the iden tified themes, guidelines were developed to accompany the nurse during the process of withdrawal of treat ment.

KEY WORDS:
Registered nurse Withdrawal of treatment Critically ill patient Euthanasia Living will
Die verhoudinge wat verpleegkundiges met in d iv id u e b e tro k k e by die o n tre k k in g van lewensondersteunende behandeling ontwikkel.2.
D ie in n e rlik e m o rele k o n flik w at d e u r verpleegkundiges beleef word ten opsigte van etiese aspekte.Die fokus van die artikel is op die bespreking van die belewinge van die geregistreerde verpleegkundiges.Riglyne om verpleekundiges deur die proses te begelei, gebaseer op die ge'identifiseerde temas, is ontwikkel.

Background and rationale
Patients in an Intensive Care Unit (ICU) are very ill and some have very poor prognoses.Certain conditions, in cluding surgical complications, debilitating illness or pro gression of illness, may result in a patient being kept alive artificially on life support machines.Mechanical ventila tion and nutritional support are the two most common meth ods used.Some critically ill patients, who have no possibility of re covering and living a meaningful life, are kept alive for months and even years on artificial life support.Body sys tems are affected by artificial life support and can result in multi-system failure.It is ultimately possible that a patient may be kept alive and, therefore, be allowed to suffer prima-^ rily because of the possible legal implications or as a result o f insistence from the family.The escalating cost of health I care is a factor that plays a role in the decision to withdraw treatment.Once a patient has died, families can be left responsible for paying large medical bills.This financial burden could be lessened if treatment was withdrawn ear lier.
Death ends all human existence and, although it is inevita ble, it is feared and avoided by most people for as long as possible.The Dying Persons Bill of Rights includes as pects such as: • Rights to treatment as a living human being until death.
• M aintenance of a sense of hopefulness.
• Freedom from pain.

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The right not to die alone.

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The right to maintain one's individuality.

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The right to be cared for by caring, knowledgeable and sensitive people (De Laune and Ladner, 2002:483).
A dying person needs to be treated with dignity and his/ her wishes must be respected because the ethical implica tions of patient autonomy, and the right to decide about treatment, are becoming more of a reality within the health care sectors (m edicine) today.A ccording to Benatar \ (1994:254), w ithholding and w ithdraw ing life support therapy, with or without palliative sedation or analgesia, / are generally, but not universally, considered to be ethi cally and legally distinct from assisted suicide and active euthanasia.At present euthanasia is illegal in South Africa and a living will is still not a legally accepted document, as stated in Taitz (1993:440).The South African Law Commis sion (1997) is currently tabling an Act regarding the afore mentioned subjects and, once promulgated, this will have a dramatic impact on the ethical considerations involved in medicine and, therefore, in nursing practice.
Nurses are seen as caregivers and part of the caring proc ess is to alleviate suffering.This situation has an em o tional impact on the nurse caring for the patient.He/she renders the nursing care to the patient who is clearly dying, while the physician or intensivist makes the decisions re garding the patient's treatment (Burrows, 1994:630).It is the nurse who accompanies the patient through this period and ensures that his/her rights are respected.A patient who is dying still needs to be cared for.Symptoms need to be assessed and treated.A nurse who has to work with-a dying patient, must he dedicated to what is the bottom line in good terminal care, the highest possible degree o f physical comfort available in each situation (Ellis, 1995:53).
In order to understand the emotions that Registered Nurses experience when treatment is withdrawn from a patient and death is imminent, it is necessary to gain a deeper insight into their experience of the situation and the coping mecha nisms that they use.A study undertaken as far back as 1962 by Seele (1962:100) on the "Attitudes of Medical Students and Practitioners towards Euthanasia" recommended that the above study should be carried out amongst nurses as they have more contact with patients.A deeper under standing will facilitate development of guidelines to assist Registered Nurses to be better equipped to cope with the situation in the future.Very few studies have been docu mented in which the experiences of the nurse have been investigated.Within the proposed study, the researcher aims to gain the insight needed to guide the nurses and, therefore, enable them to cope more effectively with the situation.

Problem statement and objectives
Many nurses working in Intensive Care Units are frequently confronted with death, especially the death of patients whom they have nursed over a long period of time.These deaths are often as a result of the withdrawal of treatment in cases where further medical treatment will have no ben eficial effect on the patient's poor prognosis.
The researcher, who is employed in an environment in which withdrawal of treatment occurs, has observed, as a result o f the way in which they react following the prescription of the withdrawal of treatment by the doctor, that colleagues appear to experience this process negatively.During the process of treatment withdrawal the nurse experiences a variety of em otions and the stress involved can have a significant impact on the mental health of the nurse execut ing the prescription.Many factors are involved which cul minate in a complex experience for the Registered Nurse.
The manner in which the nurse copes with the process can impact negatively on his/her emotions and influence the way in which he/she approaches a similar situation in the future.
In order to understand the experiences of the Registered Nurse in an Intensive Care Unit, specific factors that have an influence on the nurse's experience of the withdrawal of treatment from a critically ill patient were investigated.These were determined through the research process by answer ing the following questions: 1. W hat is the experience of the Registered Nurse, The use o f an independent coder to analyse study and discuss findings with researcher.Should this be necessary to ensure accurate data analy sis, the data will be left for two weeks after initial analy sis and then be recoded.Identified themes will then be compared and used.Independent coder who is also a Registered Nurse used to assist with data analysis.

As discussed above
As discussed above working in an Intensive Care Unit, of the withdrawal of treatment from a critically ill patient? 2. W hat guidelines can be developed to support the Reg istered Nurse in this situation?
The goals of the research were, therefore, to: • Identify, explore and describe the experiences of the Registered Nurse, working in an Intensive Care Unit, with regard to the withdrawal of treatment from a critically ill patient.
• Develop guidelines for the accompaniment of the Registered Nurse throughout the process of with drawal of treatment.

Research design and method
The research was qualitative in design and descriptive and exploratory in nature, since no such work amongst Regis tered Nurses has yet been documented within a South Af rican context.The approach was contextual because it cov ered the experiences of Registered Nurses in Intensive Care Units.The study was also phenomenological by way of the research er explo rin g the actual lived experience (Haegert, 1997:48) of the Registered Nurses regarding the withdrawal of treatment from critically ill patients.
Data was collected by means of phenomenological inter views using the principles of interviewing as defined in Kvale( 1996:30).

Data Collection
Purposive sampling was utilized to recruit participants.
Purposive sampling is based on the assumption that a re searcher's knowledge about the population can be used to handpick the cases to be included in the sample (Polit and Hungler, 1999:229).The sample population fron\which par ticipants were chosen comprised Registered Nurses work ing in two private hospitals in Port Elizabeth for a minimum of three months.
Appointments were made with participants who were ran domly chosen to participate in the study.Data was col lected by phenomenological interviews with six participants.
A seventh interview was executed in order to ensure ad equate data saturation.All the interviews were audiotaped and transcribed verbatim.Field notes were taken.
The question on which the interviews were based was as follows: "Describe your experience related to the withdrawal of treat ment from a critically ill patient."

Data Analysis
Data analysis followed the verbatim transcription of the interviews.This was done by the researcher, as well as an independent coder.Data analysis was done using the steps described by Tesch (in Creswell 1994:155).All the tran scribed interviews were perused and ideas were jotted down in the margins.Categories and themes of the Nurses' expe riences were identified and formulated.Once this process was com pleted, discussions were held between the re searcher and the independent coder to confirm the identi fied themes.G uba's model (in Krefting 1991:214) was used to ensure trustworthiness in the research.The four criteria of trust worthiness, viz truth-value, applicability, consistency and neutrality were used.The strategies of transferability, con sistency, dependability and confirmability were also used and applied to the study in order to attain the criteria.

Ethical considerations
Ethical principles were maintained throughout the study in order to protect the participants from harm.The principles, as set out in the Ethical Standards for Nurse Researchers (South African Society for Nurse Researchers, 1996:74), were adhered to.These include maintenance of confidentiality and anonymity, avoidance of harm and obtaining of in formed consent from the institutions involved, as well as each participant.The participants were given the option to withdraw from the research at any time.The quality of the research was ensured by informing participants fully about the goal of the study, the method of research, what was expected o f them, how results would be used and pub lished and that confidentiality and anonymity would be maintained throughout.

Discussion of results
The following is a study of the results.All statements have been supported by quotes from the original text.A litera ture control was done to verify the findings.Results of the research are summarised in table 2.
Theme 1 : Nurses developed relationships with certain individuals related to the process of treatment withdrawal from a critically ill patient in an ICU.
Category 1: Intrapersonal relationships which the nurse developed.The nurse stood in relationship with himself/ herself and experienced the process of treatment with drawal as very emotional.
In the first sub-category the emotions that the nurse expe riences throughout the process of treatment withdrawal were identified.
• Through the interview process, some of the partici pants expressed feelings of guilt related to the process of withdrawal o f treatment.The participants also reported ex periencing conflict because of the decision, since nurses are taught to preserve life and now the prescription is given to allow death to take place by withdrawing life-sustaining measures."Indirek is jy verantwoordelik vir daai....die dood van die pasiënt" (Indirectly you are responsible fo r the p a tie n t' s death).Cartw right, Steinberg, W illiams, Najman & Williams (1997:81) state that, since nurses are trained to prolong life they may be distressed when active medical intervention for a dying person is stopped.

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The participants expressed feelings of sadness for the loss o f the life of a patient who had been looked after for a long period of time.Despondency was caused by the fact that, no matter what was done for the patient, death was inevitable and, thus, the time spent caring for the pa tient appeared futile."We have got to go through all that and then switch o ff the ventilator in the end.Which I have done only once and which I will never do again." Schnei der (1997:179) confirms the feeling of sadness that nurses experience associated with the situation of the withdrawal of treatment.
Table 2 .Identified themes of the Registered Nurses' experience of the withdrawal of treatm ent from the critically ill patient in an ICU Themes: Categories: Sub-Categories: 1.
The relatio n sh ip s the nurse develops with certain individuals re lated to the process of treatment with drawal from a critically ill patient in an ICU

1.1
In trap erso n al rela tio n sh ip s which the nurse develops with him/ h erself throughout the process of treatment withdrawal from a critically ill patient in an ICU

1.2
Interpersonal relationships the nurse develops with other individuals related to the process o f treatm ent withdrawal from a critically ill patient in an ICU 1.1.1The emotions the nurse experi ences throughout the process of with drawal of treatment 1.1.2The coping m echanism s the nurse employs to protect him/herself within the situation of withdrawal of treatment 1.1.3An expressed need for em o tional support and knowledge regard ing the process and the ethics in volved during the withdrawal of treat ment 1.2.1 The nurse's relationship with the patient for whom he/she is caring 1.2.2The nurse's relationship with the family of the patient from whom treatment is being withdrawn 1.2.3The professional relationship the nurse develops with the doctor treating the patient 2.
The moral conflict the nurse has within him /herself related to the ethical aspects o f withdrawal of treat ment

2.1
The influence of religion on the nurse's experience of the process of withdrawal of treatment from a criti cally ill patient in an ICU 2.2 The role of a living w ill/ad vanced directive in the process of treatment withdrawal from a critically ill patient in an ICU 2.3 The role of the nurse as patient advocate 2.4 The role of the nurse in accom panying the patient to a dignified death

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The participants expressed feelings of helplessness.This was based on the fact that, although everything was attempted to save a patient's life, there was no possibility of recovery and treatment was therefore withdrawn.''I mean you ju st fe e l so helpless, there is nothing you can do ".In a study done by Schneider (1997:174), she stated that nurses experienced loss and helplessness.

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The participants expressed feelings of frustration where unnecessary treatment was prolonged in situations where patient recovery seemed impossible but the doctor was not prepared to make the final decision to withdraw treatment.Anger, especially at the doctor concerned, was also identified through the interviews."They m ustn't pro long that agony because that waiting is ju st too terrible fo r words.I d o n 't think they should.I think if they are going to stop treatment, they m ust make a decision be cause obviously they m ust be very clear in their minds that they are going to stop treatment and stop it and that is the end o f it." In a study done by Asch, Shea, Jedrziewske andBosk ( 1997: 1661) many nurses revealed frustration with the phy sicians and frustration with their own limited ability to intercede on their patients' behalves.

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The involvement of the nurse with the patient and the family may cause the nurse to become very emotionally drained.This concern was expressed by some of the par ticipants during the interviews.The participants were per ceived to be very empathetic towards the families and their suffering but showed a reluctance to become too involved with the families, as this could drain them emotionally."It is draining on the nursing sta ff to have these people....This emotion around you all the time."

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The participants wanted to keep the flame of hope alive for the patients and the families but often reality in truded making it difficult to stay hopeful."I actually spoke to the daughter and to the son., uhm.. and you know he was ju st saying i f there is hope then prolong yes, then go fo r it.But i f there is no hope what is the point in going on ?A nd then coming in and seeing their fa th er like this, you know, uhm ...and ju st getting worse and knowing that ac tually he has got no prognosis so ".One of the patient's rights, according to the Dying Persons Bill of Rights (De Laune and Ladner, 2002:483), is the maintenance of a sense of hopefulness.
generally your colleagues are there, they understand the situation because they go through it themselves." Curtin & Flaherty (1982:233) explain that the emotional effects of the conflict the nurse experiences should never be under estimated.

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Another method used by nurses was to "work it o ff".The individual executes certain actions to relieve the tension caused by the experience of treatment withdrawal.Some o f the participants identified certain actions that helped in relieving the tension that had built up within them." / ju st go home and cry ''.

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Notice was taken of the emotional fluctuations ex perienced by the participants.The sadness of losing a pa tient was contrasted with the joy of having a patient trans ferred as his condition improved."I mean especially in ICU you see the whole spectrum.You see the utmost joy and the real, real misery.So you have got the broad spec trum o f emotions." Curtin & Flaherty (1982: 233) explain that the emotional effect of the conflict the nurse experi ences should never be underestimated.
In the second sub-category it was identified that the nurse em ploys coping m echanism s to protect him self/herself within the situation of withdrawal of treatment.

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Nurses used rationalisation or justification to con struct logical or socially acceptable explanations for the decision-making process regarding treatment withdrawal.When the process is justified it is more acceptable for the nurse and, thus, easier to execute.The steps involved in treatment withdrawal need to be prescribed by the physi cian.Participants reported that this helped them to justify treatment withdrawal and alleviated those feelings of guilt that may have occurred, as they were executing a doctor's prescription.".. i f I believe that I am doing the right thing le a n justify i t ".A phenomenological study done by Viney (1996:182) confirms the findings of nurses justifying their actions.

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The nurses also explained that, at times, they with drew emotionally from the patients by distancing them selves or avoiding involvement.This coping mechanism was used by some of the participants in order to protect their own emotions and prevent themselves from becom ing too involved in the suffering o f the patient and the family.In reality, in order to protect their own sanity, the participants relied on the utilization of the coping mecha nisms of avoidance or withdrawal."You will probably with draw ".Wilson & Kniesel (1989:138) confirm that one way individuals cope with stress is to withdraw physically and/ or emotionally.

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Sometimes the nurses coped by turning to a com forting person.This coping strategy was identified as the nurse seeking another figure for nurturing and protection (Wilson & Kniesel. 1989:138).Within the situation of with drawing treatment, the participants reported that this fig ure was often one of their colleagues who had been through similar situations and could empathise with them."But

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By using the coping mechanism of self-discipline some of the nurses employed a strategy o f self-control.This encompasses personal admonitions to "keep a stiff upper lip", "bite the bullet" and "get over it" and to sup press one's emotion.This forces the participant to main tain professionalism in such a manner that emotional in volvement is wholly avoided.By acting in such a manner, the nurse is able to maintain a clinical approach to the proc ess of withdrawal of treatment."Uhm you basically cut your emotions, not to become too involved.You know you basically almost deal with it uhm.. in a clinical way.You can be very empathetic towards the patients but you make sure that your emotions do not become involved'.

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Intellectualisation was used by nurses because it separates their emotions from the situation o f treatment withdrawal by concentrating on the theoretical information related to the process.The nurse gives a rational explana tion for the situation he/she is in and, thus provides a ver bal means of coping with the anxiety he/she is experiencing (Wilson & Kniesel. 1992:96) ."All the one's that / have nursed, have had, I mean every system has been damaged.They had been in renal failure, they have got no neuro activity, you know, thqt is worth mentioning, they have all been on m ajor doses o f inotropes and... you know you have to.. / think sometimes ...you don't have to save a life, you d o n 't have to pull out all the stops, because you have got to think about the quality o f that p erso n ' s life after wards... ".

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Some nurses also relied on previous experience of similar situations.The memory of how they coped during a prior experience of treatment withdrawal plays a role in the experience of a current situation of treatment withdrawal." You can't experience it every day, but 1 think that every time you are exposed to it, it actually helps uhm.... "Dit berei jo u voor vir die volgende situasie "...( " It prepares you fo r the next situation ").Schneider (1997:180) describes how treatment withdrawal situations can be more upset ting for the inexperienced nurse.
In the third sub-category the need fo r emotional support and knowledge regarding the process and the ethics in volved during the withdrawal o f treatment was expressed.A need for knowledge of the ethical aspects o f death and dying related to the process of treatment withdrawal, as well as the need for skill involved in the accompanying of patients and relatives involved in the process of the with drawal of treatment, was identified within the interviews.

"D a a r is 'n g e w e ld ig e g ro te b e h o e fte aan d ie voorbereiding wanneer die dag dokter vir joit sê spuit, sit a f die ventilator.... "(
There is a great need fo r prepara tion fo r the day when the doctor says inject, switch o ff the ventilator.)Schneider (1997:183) also identified a need for educating nurses with regard to the issues relating to treat ment withdrawal.
Category 2: The interpersonal relationships developed between the nurse and other individuals related to the proc ess of treatment withdrawal from a critically ill patient in an ICU.The first sub-category identifies the development of a re lationship between the nurse and the patient for whom he/she is caring.
Often a patient from whom treatment is being withdrawn is sedated or comatose but the nurse still has contact with the individual and, through this contact, a bond is formed.The nurse sees the pain on the patient's face when turned.He/she tends to the patient's hygiene and wounds and is aware of his/her general condition."Your relationship with the patients themselves, the relationship with the rela tives.. Uhm some are easier to do than others ....if you have been nursing the patient fo r a length o f time or the patient has ju st come in and it depends on the age o f the patient., but....there comes a time that you know it is the right time to do ju st that and i f you know that then i t ... then it does make it a bit easier".Cartwright et al (1997:82) describes the empathetic relationship that develops between the nurse, the patient and their family.
The second sub-category identifies the development of a relationship between the nurse and the fam ily o f the pa tient from whom treatment is being withdrawn.

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The nurse patiently tends to the fam ily's questions, fears, uncertainties and frustrations regarding the patient's condition and also observes and experiences the family within this situation o f illness and treatment withdrawal and develops an empathy for what they are experiencing: " Uhm I ju st fe e l fo r them standing around the bed.I fe e l fo r them not understanding w hat' s really going on.This hope less situation and you build up a bond with the relatives and uhm...I do fin d the relatives a big part o f dealing with the ... with the., actual decision to stop the treatment on the patient".Schneider (1997:179) also identifies the close ness of the relationship between the nurse and the family resulting in the likelihood of the nurse empathising with the feelings and the experience o f the family.

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The nurses also expressed uneasiness in terms of the family with regard to the financial implications of pro longed treatment."... you know the fa m ily financially can't cope with this.That they have got these fea rs o f what i f the medical aid d o esn 't p a y " Atkinson et al (in Schnei der, 1997:174) identifies that ICU care is very expensive, with the greatest expenditure likely to be allocated to non survivors. ' The third sub-category was the professional relationship the nurse develops with the doctor treating the patient.Within this situation, the participants experienced the doc tor as uninvolved, distant and not open to discussion with staff and the families o f patients regarding the decision of continuing or withdrawing of treatment.Participants also suggested a reluctance in the doctors concerned to face the reality of the situation, that no matter what treatment was being administered the patient would not get any bet ter: "They don't lift the blankets and look at the wounds, they d o n 't ... they don't look at that person as a husband or a fa th er or a part o f a fam ily and they d o n 't think o f the suffering ".In the study done by Asch et al (1997Asch et al ( :1661)), the nurses were noted as having discussed physicians' roles in caring for seriously ill patients and many of these com ments were critical of the practices of the physicians.
Theme 2: The nurse experiences a moral conflict within him/herself related to the ethical aspects of the withdrawal of treatm ent.
Withdrawal of treatment is a highly controversial act due to the fact that one is hastening the death o f an individual.This leads to a situation in which the nurse is faced with an ethical problem.The following ethical dilemmas were iden tified: Category 1: The influence of religion on the nurse's expe rience of the process of treatment withdrawal from a criti cally ill patient in an ICU.
Through the development of moral values within a reli gious perspective, withdrawal o f treatment can be very controversial.Within this perspective the question is raised, "Who has been given the right to take life?" Participants experienced conflicts and questions within themselves, ir respective o f the higher power to whom they felt account able.This also influenced their experience of the with drawal of treatment."The big part is feeling helpless that you want to do so much more and being a religious per son you know that you have done everything humanly possible and the rest is in G od' s ha n d s".
Category 2: The role of a living will/advanced directive in the process of treatm ent withdrawal from a critically ill patient in an ICU was described.
An advanced directive/living will, in which the patient signs a document stating that he/she does not want life-prolonging treatment, can also assist the nurse and the doctor in the dilemma inherent in the decision-making process in treatment withdrawal.Participants referred to a living will and the effect it would have on the decision to withdraw treatment.However, only one participant noted that a liv ing will had actually been used in the ICU in which that R egistered N urse p ractised.

Guidelines
The insights gained from the themes were used to develop guidelines for the accom panim ent of Registered Nurses during the process of withdrawal of treatment:

D evelopm ent o f a unit policy with regard to the institution and maintenance o f life prolonging treatment
Guidelines must be set up with regard to resuscitation of patients.The use o f scoring scales to determine prognosis will facilitate earlier withdrawal of treatment and prevent prolonging of suffering.Ethical Committees must be insti tuted to assist in decision-making.These support systems will lessen the feelings of guilt and enable the nurse to execute necessary processes, feeling justified and secure that what is being done is the correct, action for the specific patient.

Provision o f access to proper counselling services fo r nurses working in ICU
Debriefing facilities need to be instituted so that the nurse has the opportunity to share emotions experienced with a counsellor and to receive the necessary assistance.The counsellor can also teach the staff coping mechanisms re lating to treatment withdrawal and death.

Preparation during basic training with regard to the ethical principles o f withdrawal o f treatment
Student nurses need to be exposed during their basic train ing period to all the ethical implications and the raw emo tions related to treatment withdrawal.This accompaniment of the student through the process will assist in preparing him/her to deal with it as a registered nurse.

Implementation o f legislation regarding the Bill on Euthanasia (see South African I m w Commission, 1997) and a living will/advanced directive as a unit policy
This will make the situation of treatment withdrawal easier for the nurse involved because, firstly, it should help to reduce guilt feelings and, secondly, the knowledge that he/ she is acting within the acknowledged legal parameters should alleviate anxiety.

D evelopm ent o f skills by the Registered Nurse to assist him /herself in coping with the fam ily o f the patient from whom treatm ent is being withdrawn
The registered nurse has the responsibility of accom pany ing the family through the process of treatment withdrawal with all of its related uncertainties.He/she therefore needs to develop the skills necessary to assist the family with regard to informed decision-making and, thus, accompany the family in such a way that they are reassured that their loved one is being cared for by empathetic nurses.

Im provem ent o f relationships with doctors in volved in treating patients in the ICU
The registered nurses experience doctors as lacking involve ment in the actual process o f treatment withdrawal.This situation needs to be addressed by instituting multi-disciplinary meetings where withdrawal of treatment can be dis cussed openly and related feelings can be expressed.The institution of a decision-making body, such as an Ethical Committee, with medical and nursing representation, should also facilitate the development o f improved relationships.

Recommendations
The recommendations are made with specific reference to nursing practice, nursing education and nursing research perience of withdrawal of treatment and death needs to be included in the curriculum during basic train ing of nursing students.
• N ursing P ractice: By implementing the guidelines as mentioned above, the nurse will be accompanied in his/her practice when treatment has to be with drawn.Involving all the members of the multi-pro fessional team will allow each to have an impact on how the nurse experiences his/her practice of nurs ing.Ethical committees instituted within each hos pital, as a decision-making power regarding ethical concerns, may be beneficial in the situation of treat ment withdrawal.
• N ursing R esearch: The study can be used as a basis for further research regarding the phenom enon of treatment withdrawal or passive euthana sia.The impact of the Bill on Euthanasia (see South African Law Commission, 1997), once legalized, can be a basis for further research in nursing.This field of study can also be used to determine the medical practitioner's viewpoint on the withdrawal of treat ment.

Limitations of the study
The researcher identified the following limitations: • Difficulty was encountered in securing interviews with certain participants.After the second unsuc cessful attempt to secure an interview, the next par ticipant was contacted.• A multi-cultural approach was not obtained, as all the participants interviewed were Caucasian.
• There was lack o f supporting data regarding the Registered N urse's experience of the withdrawal of treatment from a critically ill patient in an ICU.

Conclusion
Through the study, the researcher realised that many nurses experiencing the situation of treatment withdrawal appear to experience it in isolation.Many of the nurses employ such good defence mechanisms that they are reluctant to actually share how they are really feeling.
Through this study, some of those feelings and experiences were shared.It is the researcher's intention, through this study, to show other nurses working in ICU's that the expe riences of nurses associated with the withdrawal of treat ment are similar and that they do not have to deal with them alone.Through the literature control the experiences were confirmed as universal and, thereby, deduced to be normal amongst nurses experiencing the withdrawal o f treatment from a critically ill patient in an ICU.

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Nursing Education: The expressed need for know ledge regarding the process of the withdrawal of treatment must be addressed.The extent of the ex Curationis February 2005

Table 1 :
A summary of the strategies implemented in order to ensure trustworthiness

The role o f the nurse in accom panying the patient to a dignified death was described.
"B aie van ons p a siën te het... uhm ... vorms geteken vir genadedood -'to stop treat m e n t'.Dan dink ek nie ons verpleegsters moet daarteen gaan nie, ons m oet die pasiënt se laaste wil, m oet ons respekteer.D aarom m oet dit toegestaan word uit die pasiënt se oogpunt uit en sy laaste wil en testament moet ons dan respekteer" (M any o f our patients have.... signed fo rm s... to stop treatment.Then I think we as nurses must not go against them, we m ust respect the p a tie n t' s last wish.Therefore, from the patient's viewpoint, it must be executed, and we must respect his last will and testament.)