BACKGROUND: Integrity is a core value for delivering ethical health care. However, there is a lack of precision in defining what integrity is and how nurses understand it. In the setting of nurses caring for critically ill and dying patients in intensive care units (ICUs), integrity has not received much attention. Therefore, the aim of this study was to explore how nurses perceive and maintain the integrity of patients during end-of-life care in the ICU setting.

METHODS: This study had a qualitative descriptive design. Data were collected using individual semi-structured interviews with 16 intensive care nurses working at ICUs in four Swedish hospitals. The data were analysed by applying qualitative content analysis.

RESULTS: Five overall categories were explored: seeing the unique individual; sensitive to patient vulnerability; observant of patients' physical and mental sphere; perceptive of patients' religion and culture; and being respectful during patient encounters. Many nurses found it difficult to define integrity and to explain what respecting integrity entails in the daily care of dying patients. They often used notions associated with respect and patient-centred attitudes, such as listening and being sensitive or by trying to describe good care. Integrity was nonetheless seen as a central value for their clinical work and a precondition for ethical nursing practice. Some nurses were concerned about patient integrity, which is at risk of being "wiped out" due to the patient's illness/injury, unfamiliarity with the ICU environment and utter dependence on others for care. Protecting patients from harm and reducing patient vulnerability were also seen as important and a way to maintain the integrity of patients.

CONCLUSIONS: The study results show that even though integrity is a fundamental ethical concept and a core value in nursing, ethical codes and guidelines are not always helpful in clinical situations in the end-of-life care of ICU patients. Hence, opportunities must regularly be made available for ICU nurses to reflect on and discuss ethical issues in terms of their decision-making and behaviour.

Background: In Swedish intensive care units, nine percent of patients do not survive despite receiving advanced life-sustaining treatments. As these patients transition to end-of-life care, ethical considerations may become paramount.

Aim: To explore the ethical challenges that critical care nurses encounter when caring for patients at the end of life in an intensive care context.

Research design: The study used a qualitative approach with an interpretive descriptive design.

Research context and participants: Twenty critical care nurses from eight intensive care units in an urban region in Sweden were interviewed, predominately women with a median age of fifty-one years.

Ethical considerations: This study was approved by The Swedish Ethics Review Authority.

Findings: Critical care nurses described encountering ethical challenges when life-sustaining treatments persisted to patients with minimal survival prospects and when administering pain-relieving medications that could inadvertently hasten patients' deaths. Challenges also arose when patients expressed a desire to withdraw life-sustaining treatments despite the possibility of recovery, or when family members wanted to shield patients from information about a poor prognosis; these wishes occasionally conflicted with healthcare guidelines. The critical care nurses also encountered ethical challenges when caring for potential organ donors, highlighting the balance between organ preservation and maintaining patient dignity.

Conclusion: Critical care nurses encountered ethical challenges when caring for patients at the end of life. They described issues ranging from life-sustaining treatments and administration of pain-relief, to patient preferences and organ donation considerations. Addressing these ethical challenges is essential for delivering compassionate person-centered care, and supporting family members during end-of-life care in an intensive care context.

Background: In intensive care units, critically ill patients often require life-sustaining interventions. When these no longer benefit the patient, care is often transferred to end-of-life care. Family members may find themselves in a stressful situation, since they often act as proxies in decision-making processes, and support the patient nearing the end of life, while also coping with their own grief. The aim of this study is to investigate bereaved family members' satisfaction with care, decision-making, the patients' last hours of life, and their own self-rated health in end-of-life care in an intensive care setting.

Method: A descriptive cross-sectional design with the questionnaire Family Satisfaction with Care in the Intensive care unit (FS-ICU 24) and its subscales FS-ICU Care and FS-ICU Decision-making was used: Bereaved family members from seven intensive care units in an urban region in Sweden participated. Data were analysed using descriptive and inferential statistics.

Results: Bereaved family members (n=141) reported an overall satisfaction with the end-of-life care given, summary score 77.6 (SD=20.4) on the FS-ICU Total. For the subscale FS-ICU Care the summary score were 79.5 (SD=19.9), and for FS-ICU Decision-making 74.8 (SD=23.3). Dissatisfaction were reported by 12.3% (n=17) of the family members with insufficient emotional support, 14.7% (n=20) within consistent information, and 17% (n=24) with limited control over patients' care. Family members who rated their health as worse compared to a year ago, reported lower satisfaction in FS ICU Decision-making (p=0.05).

Conclusion: This study shows an overall high satisfaction with end-of-life care in ICUs with summary scores in theupper quarter as measured by the FS-ICU 24. This study also uncovers a lack of attention to theindividual needs of family members. Dissatisfaction stemmed from the items concerning insufficientemotional support, inconsistent information, and limited control over patients´ care. These findingsunderscore the importance of paying attention to family members who express dissatisfaction withcare and decision-making and items that received the lowest satisfaction scores. It is of paramountimportance that when patients are cared for in ICU at the end of life, family members needs areidentified and measures are taken to meet those needs.

Objectives: This study aims to describe bereaved family members experiences of end-of-life carefollowing the death of a close person in ICU.

Methods: A qualitative descriptive design was used. Semi-structured interviews were conducted with 22 bereaved family members (18 women and 4 men, aged 26 to 81). The inclusion criteria were being abereaved family member of an adult patient who had died in one of the seven participating ICUs, beingat least 18 years old, and proficient in Swedish. Data was analyzed using reflexive thematic analysis.

Results: The findings are described in five themes: Time filled with fear and uncertainty, Challenges in understanding critical information, Struggling to grasp the imminence of death, Fear of patient had suffered at the very end of life, and The importance of farewell in the ICU. Family members described the transition from active treatment to end-of-life care as being unclear, with the realization of death was approaching occurring gradually and sometimes suddenly, leading to confusion and distress. The opportunity to take farewell, whether through physical presence, shared silence, or collective rituals, was described as essential to finding peace and fostering emotional closure.

Conclusions: In ICUs, family members are in great need of compassionate support, characterized by the presence of ICU nurses and their emotionally attuned communication. This support helps family members navigate the complexity in care, fostering trust, meaning-making, and a sense of dignity.

Implications for Clinical Practice: It is important that ICU nurses have the possibility to prioritize sensitive, individualized communication, emotional support, and opportunities for meaningful farewells. Flexibly accommodating family members' needs and preferences at the end of life is central to delivering respectful family-centered care.