ICU readmission refusal among patients with cancer: a qualitative study of autonomy disruption, psychological reactance, and nursing communication

Technical Summary: ICU Readmission Refusal Among Patients with Cancer

Problem Statement
Advances in oncology and critical care have increased the likelihood of patients with cancer requiring Intensive Care Unit (ICU) admission during acute deterioration. While ICU care offers physiological support and recovery opportunities, it is often associated with invasive procedures, immobility, communication barriers, and a loss of control. A specific clinical challenge arises when patients who have previously experienced ICU care explicitly refuse readmission should their condition deteriorate again. In clinical practice, such refusals are frequently misinterpreted as pessimism, non-adherence, or abandonment of care. However, these interpretations may overlook the psychological and existential dimensions of the decision. There is a lack of understanding regarding the psychological mechanisms underlying refusal of ICU readmission among cancer survivors of critical care, particularly how prior experiences shape current decision-making and how autonomy is perceived and negotiated in this context.

Methodology
This study employed a phenomenologically informed qualitative design to explore the lived experiences of patients with cancer who refused ICU readmission following a prior ICU stay.

• Setting and Participants: The study was conducted at a tertiary cancer hospital in Sichuan Province, China, between June and December 2024. Fifteen adult participants (aged 33–79) with a pathological diagnosis of cancer, prior ICU admission, and an explicit refusal of future ICU readmission were recruited via purposive sampling.
• Data Collection: Semi-structured, face-to-face interviews were conducted in Chinese (Mandarin or local dialect). The interview guide was designed to minimize leading questions, focusing on previous ICU experiences, views on readmission, and the factors influencing decision-making. Interviews lasted 20–40 minutes and were audio-recorded and transcribed verbatim.
• Analytic Approach: Data analysis followed Colaizzi's seven-step phenomenological method using NVivo 12.0. The study utilized an abductive approach, integrating inductive thematic analysis with Psychological Reactance Theory as a sensitizing framework. Initial coding was inductive, grounded in participant narratives. Psychological Reactance Theory was subsequently applied to interpret patterns related to perceived threats to freedom and resistance behaviors, without imposing a priori coding categories.
• Rigor: Trustworthiness was ensured through purposive sampling, investigator triangulation, member checking (returning transcripts to participants), and an audit trail. The study adhered to COREQ and SRQR reporting guidelines.

Key Results
The analysis identified four interrelated themes describing refusal of ICU readmission as a dynamic process of autonomy restoration:

1. ICU Care as Embodied Loss of Autonomy: Participants described previous ICU stays not merely as rescue efforts but as experiences of "embodied loss." This included a loss of bodily control (due to tubes, restraints, and immobility), marginalization in treatment decisions (feeling like bystanders to medical data), and an erosion of social and personal identity (fear of being reduced to a "patient number" or losing dignity in the eyes of family).
2. ICU Readmission as a Perceived Threat to Freedom: Resistance intensified when readmission was perceived as externally imposed. Key drivers included information asymmetry (unclear explanations of post-ICU quality of life), pressure from medical authority (recommendations perceived as commands), and emotional pressure from family members (feeling caught between protecting loved ones from grief and protecting oneself from suffering).
3. Psychological Reactance Expressed Through Anger, Avoidance, and Refusal: When autonomy was perceived as threatened, participants exhibited psychological reactance. This manifested as emotional outbursts (anger directed at clinicians or family), avoidance and delay of discussions, and explicit verbal refusal. These behaviors were interpreted as attempts to restore a sense of control.
4. Reconstruction of Autonomy Through Boundaries, Information, and Surrogacy: Refusal was not a blanket rejection of care but a complex negotiation. Participants reconstructed autonomy by:
   • Setting Treatment Boundaries: Accepting conditional or time-limited ICU trials with explicit stopping rules.
   • Information Seeking: Actively seeking realistic details about burdens and outcomes to reduce uncertainty.
   • Delegating to Trusted Surrogates: Entrusting decision-making to family members who understood their values, viewing this as a continuity of autonomy rather than a surrender.

Significance and Claims
The paper claims that refusal of ICU readmission among patients with cancer should be understood not as simple treatment rejection or non-compliance, but as a dynamic process of autonomy restoration shaped by prior ICU experiences and the communication context.

• Theoretical Contribution: The study posits that Psychological Reactance Theory offers a useful lens for understanding resistance behaviors (anger, avoidance) as motivational states aimed at restoring threatened freedom. However, the authors caution that reactance is only a partial explanation; refusal also involves stable, value-based boundaries and relational autonomy.
• Clinical Implications: The authors argue that nurses and clinicians should interpret refusal as a signal of perceived autonomy threats, dignity concerns, or anticipated suffering. This perspective supports a shift from persuasive communication to values clarification. Specific implications include:
  • Framing ICU care as one option within a broader trajectory.
  • Providing patient-centered explanations of the lived consequences of ICU care.
  • Supporting structured, time-limited ICU trials with clear goals and stopping rules.
  • Facilitating early alignment with surrogate decision-makers who reflect the patient's values.

Limitations
The authors acknowledge the study is limited by its single-site design in a Chinese tertiary cancer hospital. They note that cultural factors, such as hierarchical clinician-patient relationships and family-centered decision-making norms, may influence the findings, suggesting that future research should explore these processes across different cultural and healthcare contexts.