Acute and critical care nurses frequently confront the dilemma of how to care for elderly patients who pull at or attempt to remove the technologic devices, such as endotracheal tubes and intravascular lines, that are necessary for their immediate care and recovery. This phenomenon, termed "treatment interference," can have life-threatening consequences particularly for critically ill elders. This participant observation study examined the behavioral cues, patient attributes, and circumstances surrounding treatment interference in critically ill elders and nurses' responses to this problem. Grounded theory techniques were employed using field observation, formal interviews, and document analysis. Data were collected in the medical intensive care and intermediate intensive care units of a metropolitan teaching hospital. Sixteen older adults (aged 64-87) were followed longitudinally; 9 critical care nurses, 4 patients, 4 family members, and 3 physicians were formally interviewed. Eleven of 16 patients died in hospital. Treatment interference is framed within the contextual process of technologic access in critically ill older adults. Access refers to use of invasive lines and tubes and noninvasive devices to visualize bodily functions for diagnostic or monitoring information, or to administer treatment. Clinicians, patients, and family members become intimately entwined in initiating, maintaining, and discontinuing technologic access. Voicelessness, limitations and possibilities, and awareness form the substantive theory of technologic access in critically ill elders. Limitations and possibilities involves weighing the perceived value, benefits, and consequences prior to the initiation and discontinuation of technologic devices. Voicelessness represents limitations in a patient's ability to communicate thoughts, needs, and desires. Advocacy, interpretation, advance directives, and effective use of alternative communication techniques mediate the terrifying and detrimental effects of voicelessness. Awareness encompasses the patient's realization of the purpose of the technologic devices, as well as an appreciation for the danger of accidental device removal. Awareness requires minimal sedation, mental alertness, and orientation. Nurses assess many factors including device dangers and patient awareness when choosing strategies to maintain access. This research illuminates the critical care nurse's pivotal role and enormous responsibility in caring for patient and technology.
Adviser: Neville E. Strumpf. Thesis (Ph.D. in Nursing) -- University of Pennsylvania, 1998. Includes bibliographical references.