Prolonged Emotional Distress among ICU Nurses Following Repeated Involvement in Family Centered Decisions about Terminal Extubation

Abstract

This study aimed to examine the severity and drivers of prolonged emotional distress among intensive care unit nurses repeatedly involved in family-centered terminal extubation decisions, identifying key ethical and interpersonal stressors to inform targeted institutional support interventions. A qualitative descriptive phenomenological design was conducted across four high-volume tertiary intensive care units in Central Punjab over a five-month period. Purposive sampling was utilized to recruit 36 registered nurses with extensive bedside withdrawal experience until theoretical data saturation was established. Data were collected via in-depth, semi-structured interviews and analyzed using Braun and Clarke reflexive thematic analysis supported by NVivo software. Analysis revealed three overarching themes: (1) the visceral burden of hands-on death withdrawal, encompassing the sensory choreography of airway removal and witnessing distressing agonal transitions; (2) relational friction and moral injury in surrogate decision-making, driven by absorbing family ambivalence, navigating acute guilt, and confronting medically perceived futility among unprepared relatives; and (3) cumulative psychological residue and behavioral adaptation, characterized by progressive unprocessed grief, profound emotional exhaustion, and defensive emotional blunting. Prolonged distress originates from acute sensory exposure, perceived clinical futility, and surrogate friction, progressively eroding empathetic capacity and prompting defensive disengagement. Healthcare organizations must transition toward structured, immediate post-extubation multidisciplinary debriefings and dedicated psychological support frameworks to preserve clinician retention and compassionate bedside care.