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Ford D, Zapka J, Gebregziabher M, Yang C, Sterba K. Factors associated with illness perception among critically ill patients and surrogates. Chest 2010; 138:59-67. [PMID: 20081097 DOI: 10.1378/chest.09-2124] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We investigated illness perceptions among critically ill patients or their surrogates in a university medical ICU using a prospective survey. We hypothesized that these would vary by demographic, personal, and clinical measures. METHODS Patients (n = 23) or their surrogates (n = 77) were recruited. The Illness Perception Questionnaire-Revised (IPQ-R) measured six domains of illness perception: timeline-acute/chronic, consequences, emotional impact, personal control, treatment efficacy, and illness comprehension. Multiple variable linear regression models were developed with IPQ-R scores as the outcomes. RESULTS African Americans tended to perceive the illness as less enduring and reported more confidence in treatment efficacy (P < .01 for each). They also tended to report the illness as less serious, having less emotional impact, and having greater personal control (P = .0002 for each). Conversely, African Americans reported lower illness comprehension (P = .002). Faith/religion was associated with positive illness perceptions, including less concern regarding consequences (P = .02), less emotional impact (P = .03), and more confidence in treatment efficacy (P < .01). Lower patient quality of life (QOL) precritical illness was associated with negative perceptions, including greater concern about illness duration and consequences as well as perception of less personal control and less confidence in treatment efficacy (P < .01 for each). These variables were independently associated with illness perceptions after controlling for race, faith/religion, and survival to hospital discharge, whereas clinical measures were not. CONCLUSIONS Illness perceptions among critically ill patients and surrogates are influenced by patient/surrogate factors, including race, faith, and precritical illness QOL, rather than clinical measures. Clinicians should recognize the variability in illness perceptions and the possible implications for patient/surrogate communication.
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Affiliation(s)
- Dee Ford
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, 96 Jonathan Lucas Dr, 812-CSB, Charleston, SC 29425, USA.
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Faith K, Chidwick P. Role of clinical ethicists in making decisions about levels of care in the intensive care unit. Crit Care Nurse 2009; 29:77-84. [PMID: 19339449 DOI: 10.4037/ccn2009285] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Karen Faith
- Clinical Ethics Centre at Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Ford D, Zapka JG, Gebregziabher M, Hennessy W, Yang C. Investigating critically ill patients' and families' perceptions of likelihood of survival. J Palliat Med 2009; 12:45-52. [PMID: 19284262 DOI: 10.1089/jpm.2008.0183] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This study investigated the perception of chance for survival among critically ill patients and surrogates and compared those perceptions to actual survival and to clinical estimates of illness severity. Secondary aims explored whether select demographic, clinical, or personal measures were associated with different perceptions of chance for survival. DESIGN Prospective, sequential, observational, survey-based study. Primary measures were perception of chance for survival as compared to actual survival and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. SETTING Tertiary care, academic medical intensive care unit (MICU). PATIENTS Subjects were English-speaking adult MICU patients with a MICU length-of-stay greater than three days or their surrogates (n = 100). RESULTS Respondents tended to be more optimistic regarding chance for survival than supported by actual survival (p = 0.07) or APACHE II tertile (p = 0.34). Secondary analyses found African American race, faith, or religion impacting health decision-making, and higher health status reports were associated with more optimistic perceptions of chance for survival. CONCLUSION Patient/surrogate perceptions of chance for survival were not associated with either actual MICU survival or illness severity (APACHE II) highlighting an opportunity to better inform critically ill patients and families regarding prognosis. Clinician recognition of patients' and families' backgrounds and values might set the stage for such discussions.
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Affiliation(s)
- Dee Ford
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Mularski RA, Puntillo K, Varkey B, Erstad BL, Grap MJ, Gilbert HC, Li D, Medina J, Pasero C, Sessler CN. Pain management within the palliative and end-of-life care experience in the ICU. Chest 2009; 135:1360-1369. [PMID: 19420206 DOI: 10.1378/chest.08-2328] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss.
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Affiliation(s)
- Richard A Mularski
- Center for Health Research, Kaiser Permanente Northwest and Oregon Health & Science University, Portland, OR.
| | - Kathleen Puntillo
- Critical Care/Trauma Program, Department of Physiological Nursing, University of California, San Francisco, CA
| | - Basil Varkey
- Department of Medicine, Division of Pulmonary and Critical Care, Medical College of Wisconsin, Milwaukee, WI
| | - Brian L Erstad
- Department of Pharmacy Practice & Science, University of Arizona College of Pharmacy, Tucson, AZ
| | - Mary Jo Grap
- Adult Health and Nursing Systems Department, School of Nursing, Virginia Commonwealth University, Richmond, VA
| | - Hugh C Gilbert
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Denise Li
- Department of Nursing and Health Sciences, College of Science, California State University, East Bay, Hayward, CA
| | - Justine Medina
- Professional Practice and Programs, American Association of Critical Care Nurses, Aliso Viejo, CA
| | - Chris Pasero
- Pain Management Educator and Clinical Consultant, El Dorado Hills, CA
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Goodridge D, Duggleby W, Gjevre J, Rennie D. Exploring the quality of dying of patients with chronic obstructive pulmonary disease in the intensive care unit: a mixed methods study. Nurs Crit Care 2009; 14:51-60. [PMID: 19243521 DOI: 10.1111/j.1478-5153.2008.00313.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RATIONALE FOR THE STUDY Improving the quality of end-of-life (EOL) care in critical care settings is a high priority. Patients with advanced chronic obstructive pulmonary disease (COPD) are frequently admitted to and die in critical care units. To date, there has been little research examining the quality of EOL care for this unique subpopulation of critical care patients. AIMS The aims of this study were (a) to examine critical care clinician perspectives on the quality of dying of patients with COPD and (b) to compare nurse ratings of the quality of dying and death between patients with COPD with those who died from other illnesses in critical care settings. DESIGN AND SAMPLE A sequential mixed method design was used. Three focus groups provided data describing the EOL care provided to patients with COPD dying in the intensive care unit (ICU). Nurses caring for patients who died in the ICU completed a previously validated, cross-sectional survey (Quality of Dying and Death) rating the quality of dying for 103 patients. DATA ANALYSIS Thematic analysis was used to analyse the focus group data. Total and item scores for 34 patients who had died in the ICU with COPD were compared with those for 69 patients who died from other causes. RESULTS Three primary themes emerged from the qualitative data are as follows: managing difficult symptoms, questioning the appropriateness of care and establishing care priorities. Ratings for the quality of dying were significantly lower for patients with COPD than for those who died from other causes on several survey items, including dyspnoea, anxiety and the belief that the patient had been kept alive too long. The qualitative data allowed for in-depth explication of the survey results. CONCLUSIONS Attention to the management of dyspnoea, anxiety and treatment decision-making are priority concerns when providing EOL care in the ICU to patients with COPD.
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Affiliation(s)
- Donna Goodridge
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
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Anderson WG, Arnold RM, Angus DC, Bryce CL. Passive decision-making preference is associated with anxiety and depression in relatives of patients in the intensive care unit. J Crit Care 2009; 24:249-54. [DOI: 10.1016/j.jcrc.2007.12.010] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Revised: 11/26/2007] [Accepted: 12/02/2007] [Indexed: 11/30/2022]
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McAdam JL, Puntillo K. Symptoms experienced by family members of patients in intensive care units. Am J Crit Care 2009; 18:200-9; quiz 210. [PMID: 19411580 DOI: 10.4037/ajcc2009252] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Concern for the family members of patients who are at high risk of dying in intensive care units is both a necessary and integral part of providing holistic nursing care. When patients are at high risk of dying, their families experience burdens such as decision making and treatment choices that can cause the families psychological and physical symptoms, most commonly stress, anxiety, and depression. These symptoms in turn can affect family members' general well-being. Since the late 1990s, several quantitative and qualitative studies have been done to assess symptoms in such family members. In this review of the literature, the current state of the science on symptoms experienced by family members of patients in the intensive care unit is reviewed and critiqued. Risk factors associated with an increase in symptoms experienced are discussed. Overall, surveys that use self-report measures were the most common study design. Limitations of the studies include convenience sampling, small sample sizes, and a lack of description of patients' characteristics, all of which make comparison and use of findings difficult. Recommendations to address gaps in the literature are highlighted, and future research goals are discussed.
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Affiliation(s)
- Jennifer L. McAdam
- Jennifer L. McAdam is an assistant professor of nursing at the School of Nursing at Dominican University of California, San Rafael. Kathleen Puntillo is a professor of nursing in the Department of Physiological Nursing, School of Nursing, University of California, San Francisco
| | - Kathleen Puntillo
- Jennifer L. McAdam is an assistant professor of nursing at the School of Nursing at Dominican University of California, San Rafael. Kathleen Puntillo is a professor of nursing in the Department of Physiological Nursing, School of Nursing, University of California, San Francisco
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Wetzig SM, Walsh C, Prescott C, Kruger PS, Griffiths D, Jennings F, Aitken LM. Having a permanent resident in intensive care: The rewards and challenges. Aust Crit Care 2009; 22:83-92. [DOI: 10.1016/j.aucc.2009.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2008] [Revised: 11/21/2008] [Accepted: 02/24/2009] [Indexed: 11/26/2022] Open
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Professionalism and communication in the intensive care unit: reliability and validity of a simulated family conference. Simul Healthc 2009; 3:224-38. [PMID: 19088667 DOI: 10.1097/sih.0b013e31817e6149] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE An Objective Structured Clinical Exam was designed to assess physician's ability to discuss end-of-life (EOL) and disclose iatrogenic complications (DOC) with family members of intensive care unit patients. The study explores reliability and validity based on scores from contrasting rater groups (clinicians, SPs, and examinees). METHODS Two 20-minute stations were administered to 17 surgical residents and 2 critical fellows at a university-based training program. The exam was conducted, videotaped, and scored in a standardized setting by 8 clinical raters (MD and RN) and 8 standardized families using separate rating tools (EOL and DOC). Examinees assessed themselves using the same tools. We analyzed the internal consistency, inter-rater agreement, and discriminant validity of both cases using data from each rater group. Cross-rater group comparisons were also made. RESULTS The internal consistency reliability correlations were above 0.90 regardless of case or rater group. Within rater groups, raters were within 1 point of agreement (5-pt and 6-pt scales) on 81% of the DOC and between 74% and 79% of the EOL items. Family raters were more favorable than clinical raters in scoring DOC, but not EOL cases. Large raw differences in performance by training level favored more experienced trainees (3rd year residents and fellows). These differences were statistically significant when based on residents own self-ratings, but not when they were based on clinical or family ratings. DISCUSSION The Family Conference Objective Structured Clinical Exam is a reliable exam with high content validity. It seems unique in the literature for assessing surgical trainees' ability to discuss "bad news" with family members in intensive care.
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Abstract
BACKGROUND Ten percent to 20% of trauma patients admitted to the intensive care unit (ICU) will die from their injuries. Providing appropriate end-of-life care in this setting is difficult and often late in the patients' course. Patients are young, prognosis uncertain, and conflict common around goals of care. We hypothesized that early, structured communication in the trauma ICU would improve end-of-life care practice. METHODS Prospective, observational, prepost study on consecutive trauma patients admitted to the ICU before and after a structured palliative care intervention was integrated into standard ICU care. The program included part I, early (at admission) family bereavement support, assessment of prognosis, and patient preferences, and part II (within 72 hours) interdisciplinary family meeting. Data on goals of care discussions, do-not-resuscitate (DNR) orders and withdrawal of life support (W/D) were collected from physician rounds, family meetings, and medical records. RESULTS Eighty-three percent of patients received part I and 69% part II intervention. Discussion of goals of care by physicians on rounds increased from 4% to 36% of patient-days. During intervention, rates of mortality (14%), DNR (43%), and W/D (24%) were unchanged, but DNR orders and W/D were instituted earlier in hospital course. ICU length of stay was decreased in patients who died. CONCLUSIONS Structured communication between physician and families resulted in earlier consensus around goals of care for dying trauma patients. Integration of early palliative care alongside aggressive trauma care can be accomplished without change in mortality and has the ability to change the culture of care in the trauma ICU.
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Holley A, Kravet SJ, Cordts G. Documentation of code status and discussion of goals of care in gravely ill hospitalized patients. J Crit Care 2008; 24:288-92. [PMID: 19327289 DOI: 10.1016/j.jcrc.2008.03.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Revised: 03/26/2008] [Accepted: 03/26/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Timely discussions about goals of care in critically ill patients have been shown to be important. METHODS We conducted a retrospective chart review over 2 years (2003-2004) of patients admitted to our medical service who were classified as "expected to die." Charts were evaluated for do-not-resuscitate (DNR) documentation and discussions of goals of care. Detailed chart reviews for demographic information, cause of death, site of death, length of stay, and duration of resuscitation attempt were performed. RESULTS Of 497 charts identified, 434 (87.3%) had a DNR on file at the time of death. After exclusion of patients who died in less than 24 hours, 18 no-DNR charts remained. Seven noted a decision to continue aggressive care and 11 had no code status discussion documented. Younger patients and patients with cardiovascular disease were less likely to have a DNR. Resuscitation times were longer in the no-discussion group. All patients who died without a DNR died in the intensive care unit. Seventy-six percent of discussions were done by medicine housestaff. CONCLUSIONS Although the overall rate of DNR documentation was high, several trends emerged. Medicine housestaff in the intensive care unit would be a logical group to target for an educational intervention to address these discrepancies.
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Affiliation(s)
- Abigail Holley
- Section of Geriatrics, Department of Medicine, University of Chicago, Medical Center, Chicago, IL 60637, USA.
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63
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Lanken PN, Terry PB, Delisser HM, Fahy BF, Hansen-Flaschen J, Heffner JE, Levy M, Mularski RA, Osborne ML, Prendergast TJ, Rocker G, Sibbald WJ, Wilfond B, Yankaskas JR. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008; 177:912-27. [PMID: 18390964 DOI: 10.1164/rccm.200605-587st] [Citation(s) in RCA: 491] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Shanawani H, Wenrich MD, Tonelli MR, Curtis JR. Meeting physicians' responsibilities in providing end-of-life care. Chest 2008; 133:775-86. [PMID: 18321905 DOI: 10.1378/chest.07-2177] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Despite many clinical examples of exemplary end-of-life care, a number of studies highlight significant shortcomings in the quality of end-of-life care that the majority of patients receive. In part, this stems from inconsistencies in training and supporting clinicians in delivering end-of-life care. This review describes the responsibilities of pulmonary and critical care physicians in providing end-of-life care to patients and their families. While many responsibilities are common to all physicians who care for patients with life-limiting illness, some issues are particularly relevant to pulmonary and critical care physicians. These issues include prognostication and decision making about goals of care, challenges and approaches to communicating with patients and their family, the role of interdisciplinary collaboration, principles and practice of withholding and withdrawing life-sustaining measures, and cultural competency in end-of-life care.
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Affiliation(s)
- Hasan Shanawani
- Division of Pulmonary and Critical Care Medicine, Wayne State University School of Medicine, Detroit, MI, USA
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65
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Abstract
Overall, critical care nursing and medical teams are inadequately prepared to deliver palliative care for the critically ill geriatric patient. Conversations with nursing and medical providers caring for the frail elderly within an intensive care unit often reveal feelings of concern for overtreatment of patients when hope for improvement has diminished. Decline of critically ill elders regularly results in conflicts and disagreements surrounding care directives among patient, family, nursing, and specialty service teams. Uncertainty shrouds the care goals as the patient declines within a critical care setting. Nursing and medical providers caring for the critically ill elderly population often waver anxiously between aggressive verses palliative care measures and are troubled by ethical dilemmas of "doing more harm than good." Collaborative, interdisciplinary practice in the face of such dilemmas offers an interactive and practical approach that promotes clinical excellence and improves quality of care for the critically ill. This article defines palliative care, discusses the complexities of caring for the critically ill older adult, and suggests recommendations for nursing practice.
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Goodridge D, Duggleby W, Gjevre J, Rennie D. Caring for critically ill patients with advanced COPD at the end of life: a qualitative study. Intensive Crit Care Nurs 2008; 24:162-70. [PMID: 18313923 DOI: 10.1016/j.iccn.2008.01.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Revised: 01/10/2008] [Accepted: 01/12/2008] [Indexed: 11/19/2022]
Abstract
Providing expert critical care for the high acuity patient with a diagnosis of COPD at the end of life is both complex and challenging. The purpose of this descriptive study was to examine intensive care unit (ICU) clinicians' perspectives on the obstacles to providing quality care for individuals with COPD who die within the critical care environment. Transcripts of three focus groups of ICU clinicians were analyzed using thematic analysis. The three themes of "managing difficult symptoms", "questioning the appropriateness of life-sustaining care" and "conflicting care priorities" were noted to be significant challenges in providing high quality end of life care to this population. Difficulties in palliating dyspnea and anxiety were associated with caregiver feelings of helplessness, empathy and fears about "killing the patient". A sense of futility, concerns about "torturing the patient" and questions about the patient/family's understanding of treatment pervaded much of the discourse about caring for people with advanced COPD in the ICU. The need to prioritize care to the most unstable ICU patients meant that patients with COPD did not always receive the attention clinicians felt they should ideally have. Organizational support must be made available for critical care clinicians to effectively deal with these issues.
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Affiliation(s)
- Donna Goodridge
- College of Nursing, University of Saskatchewan, 107 Wiggins Road, Saskatoon, Saskatchewan S7T5E5, Canada.
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Berry PA. The withholding of truth when counselling relatives of the critically ill: a rational defence. ACTA ACUST UNITED AC 2008. [DOI: 10.1258/ce.2008.008007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In cases of sudden, life-threatening illness where the chance of survival appears negligible to the admitting physician, this opinion is not always revealed during the initial meeting with the patient's relatives. Reasons as to why this withholding of the truth may be acceptable are explored through review of available evidence and personal reflection. Factors identified include: the importance of hope in families' coping mechanisms, and the instinct to preserve it; the fallibility of physicians' perception of poor prognosis in the early phase of illness; the need to avoid large swings in relatives' expectations that occur when patients appear to rally during initial resuscitation; and the adverse effect that an atmosphere of hopelessness can have on the provision of medical care. A strategy for the staged disclosure of information and the confirmation of hopelessness is then described, the aim being to find a compromise between providing a true opinion about a patient's prognosis, and regard for the opposing factors described.
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Affiliation(s)
- Philip A Berry
- Kings College Hospital, Denmark Hill, London SE5 9RS, UK
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"It's like crossing a bridge" complexities preventing physicians from discussing deactivation of implantable defibrillators at the end of life. J Gen Intern Med 2008; 23 Suppl 1:2-6. [PMID: 18095036 PMCID: PMC2150631 DOI: 10.1007/s11606-007-0237-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To understand potential barriers to physician-initiated discussions about Implantable Cardioverter Defibrillator (ICD) deactivation in patients with advanced illness. DESIGN Qualitative one-on-one interviews. PARTICIPANTS Four electrophysiologists, 4 cardiologists, and 4 generalists (internists and geriatricians) from 3 states. APPROACH Clinicians were interviewed using open-ended questions to elicit their past experiences with discussing deactivating ICDs and to determine what barriers might impede these discussions. Transcripts of these interviews were analyzed using the qualitative method of constant comparison. RESULTS Although many physicians believed that conversations about deactivating ICDs should be included in advance care planning discussions, they acknowledged that they rarely did this. Physicians indicated that there was something intrinsic to the nature of these devices that makes it inherently difficult to think of them in the same context as other management decisions at the end of a patient's life. Other explanations physicians gave as to why they did not engage in conversations included: the small internal nature of these devices and hence absence of a physical reminder to discuss the ICD, the absence of an established relationship with the patient, and their own general concerns relating to withdrawing care. CONCLUSION Whereas some of the barriers to discussing ICD deactivation are common to all forms of advance care planning, ICDs have unique characteristics that make these conversations more difficult. Future educational interventions will need to be designed to teach physicians how to improve communication with patients about the management of ICDs at the end of life.
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Abstract
Withdrawing life-sustaining technologies requires all of the resources and concepts that the field of palliative care has to offer. By learning some fundamental principles of medical management at the time of withdrawal and by mastering a few communication techniques, pediatricians, neonatologists, and pediatric intensivists can dramatically improve the care provided to their patients at the end of life. Although we may argue in pediatrics if there is ever such a thing as a good death, we should all strive to ensure one that is free of suffering, and one that supports the family in moving down a path of healthy grief and recovery.
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Affiliation(s)
- David Munson
- Division of Neonatology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Abstract
Demonstrating respect is the hallmark of excellence in caring for critically ill patients and their families. Understanding the meaning of respect and the strategies that foster it are foundational for nurses as interdisciplinary healthcare professionals. Basically, respect is the act of esteeming another. Demonstrated by word and deed, it is fostered by attending to the whole person by involving the patient and family in decision making, providing family-centered care, bearing witness, and adopting a broader perspective marked by cultural humility. By creating processes that ensure everyone's views are heard, healthcare professionals as well as patients and their families are supported. One key process, known as the "Council Process," shifts dialogue from telling to discovering, from judging to inquiring; it neutralizes conjecture, fosters the acceptance of moral conflict, and protects the integrity of healthcare professionals and their organizations. Acknowledging respect as a foundational ethical principle is the first step toward relationally rich healthcare environments for patients, families, and professionals.
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Affiliation(s)
- Cynda Hylton Rushton
- Harriet Lane Compassionate Care, The Johns Hopkins University and Children's Center, Johns Hopkins University, 525 North Wolfe St, Box 420, Baltimore, MD 21205, USA.
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72
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Dunn GP, Mosenthal AC. Palliative care in the surgical intensive care unit: where least expected, where most needed. Asian J Surg 2007; 30:1-5. [PMID: 17337364 DOI: 10.1016/s1015-9584(09)60120-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Despite dramatic improvements in survival from a broad range of afflictions seen in the surgical critical care unit, the problem of suffering in its many forms and its long-term consequences will remain as long as mortality characterizes the human condition. Palliative care in the surgical intensive care unit is an extension of time-honoured surgical principles and traditions that aims to relieve suffering and improve quality of life associated with serious illness as an end in it self or as part of treatment to save and prolong life.
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Affiliation(s)
- Geoffrey P Dunn
- Department of Surgery, Hamot Medical Center, Erie, Pennsylvania 16505, and New Jersey Medical School-University of Medicine and Dentistry of New Jersey, Newark, USA.
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Collins LG, Parks SM, Winter L. The state of advance care planning: one decade after SUPPORT. Am J Hosp Palliat Care 2007; 23:378-84. [PMID: 17060305 DOI: 10.1177/1049909106292171] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) was a landmark study regarding end-of-life decision making and advance care planning. Phase I of the study looked at the state of end of life in various hospitals, and phase II implemented a nurse-facilitated intervention designed to improve advance care planning, patient-physician communication, and the dying process. The observational phase found poor quality of care at the end of life and the intervention failed to improve the targeted outcomes. The negative findings brought public attention to the need to improve care for the dying and spawned a wealth of additional research on decision-making at the end of life. In the decade since SUPPORT, researchers have defined the attributes of a "good death," addressed the role of advance directives in advance care planning, and studied the use of surrogate decision-making at the end of life. This rekindled the discussion on advance care planning and challenged health care providers to design more flexible approaches to end of life care.
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Affiliation(s)
- Lauren G Collins
- Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
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Abstract
Intensive care units (ICUs) confront the healthcare system with end-of-life situations and ethical dilemmas surrounding death. It is necessary for all providers who treat dying patients to have a working knowledge of the philosophical principles that are fundamental to biomedical ethics. Those principles, however, are insufficient for compassionate care. To function well in the intensive care unit, one also must appreciate the behaviors that surround mortality. Human conduct is not predicated solely on rules; complex, unpredictable interactions are the norm. Palliative care, moving forward as a discipline, will become the perfect complement to intensive medical care, rather than being seen as an embodiment of its failures. We need to be as aggressive about respecting patient dignity as we are about using the technology that is central to health care. This article will outline end-of-life ethical principles, explore the sociology that influences human interactions in intensive care units, and show how palliative care should guide behaviors to improve how we deal with death.
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Affiliation(s)
- Jonathan R Gavrin
- Symptom Management and Palliative Care (SYMPAC), Pain Management Services, HUP Ethics Committee, Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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75
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Chipman JG, Beilman GJ, Schmitz CC, Seatter SC. Development and pilot testing of an OSCE for difficult conversations in surgical intensive care. JOURNAL OF SURGICAL EDUCATION 2007; 64:79-87. [PMID: 17462207 DOI: 10.1016/j.jsurg.2006.11.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Accepted: 11/05/2006] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To describe the development and results of an Objective Structured Clinical Exam (OSCE) for leading family conferences in the surgical intensive care unit (SICU). DESIGN Pilot demonstration and reliability assessment. SETTING General surgery residency program at a major academic teaching hospital. PARTICIPANTS PGY-2 and PGY-4 categorical general surgery residents (n=8). RESULTS The SICU Family Conference OSCE consists of two 20-minute stations, one requiring residents to lead an end-of-life discussion and the other to disclose an iatrogenic complication. Actual case scenarios and trained actors were used; the examinations were videotaped in a standardized setting. Two professional raters as well as the participating actors assessed each resident performance using rating tools developed for each station and based on guiding principles gleaned from the literature. Resident debriefings and evaluation surveys were also conducted. Resident perception of the OSCE overall was positive. Analysis of the videotapes revealed the need for greater standardization of the actors' roles. The rating tools showed strong internal consistency (0.77-0.85), but inter-rater agreement of scores was generally low (<0.70) within rater groups. Family actors consistently gave residents higher global assessment scores than did the professional raters. Second- and fourth-year residents scored equally well on the examination. CONCLUSIONS This pilot provided residents with a positive learning experience and valid formative feedback. Case materials developed for each station served their function well. More work in actor and rater training is needed before the examination scores can be reliably used in summative evaluation.
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Affiliation(s)
- Jeffrey G Chipman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota 55455-0321, USA
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76
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Affiliation(s)
- John Paul Slosar
- Ascension Health, 4600 Edmundson Road, St. Louis, MO 63134, USA.
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77
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Abstract
PURPOSE OF REVIEW An appreciation of a family's difficult experience in dealing with their critically ill loved ones has created the concept of 'family-centered care'. The purpose of this paper is to review the literature on the needs of the family during their intensive care unit experience. RECENT FINDINGS Families consistently highlight three major issues that they deem could be improved from their perspective. Increased information about their loved ones, proximity to the patient and a more flexible visiting policy stand out as relevant issues to families. SUMMARY Medical staff and administrators should recognize that families of critically ill patients have particular needs that help them cope with having their loved ones in an intensive care unit. Simple changes in philosophy and policy would greatly decrease the anxiety these families experience.
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Affiliation(s)
- George F Alvarez
- University of Calgary, Rockyview General Hospital, Calgary Health Region, Calgary, Alberta, Canada.
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78
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Casanueva-Mateos L, Ruiz-López P, Ignacio Sánchez-Díaz J, Ramos-Casado V, Belda-Holfheinz S, Llorente-de la Fuente A, Mar-Molinero F. Cuidados al final de la vida en la unidad de cuidados intensivos pediátricos. Empleo de técnicas de investigación cualitativa para el análisis del afrontamiento de la muerte y situaciones críticas. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1134-282x(07)71189-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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79
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Puntillo KA, McAdam JL. Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: Challenges and opportunities for moving forward. Crit Care Med 2006; 34:S332-40. [PMID: 17057595 DOI: 10.1097/01.ccm.0000237047.31376.28] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Our objective was to discuss obstacles and barriers to effective communication and collaboration regarding end-of-life issues between intensive care unit nurses and physicians. To evaluate practical interventions for improving communication and collaboration, we undertook a systematic literature review. An increase in shared decision making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers. Intensive care unit nurses value their contributions to end-of-life decision making and want to have a more active role. Increased collaboration and communication can result in more appropriate care and increased physician/nurse, patient, and family satisfaction. Recommendations for improvement in communication between intensive care unit physicians and nurses include use of joint grand rounds, patient care seminars, and interprofessional dialogues. Communication interventions such as use of daily rounds forms, communication training, and a collaborative practice model have shown positive results. When communication is clear and constructive and practice is truly collaborative, the end-of-life care provided to intensive care unit patients and families by satisfied and engaged professionals will improve markedly.
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Affiliation(s)
- Kathleen A Puntillo
- Department of Physiological Nursing, University of California, San Francisco, California, USA
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80
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Fassier T, Lautrette A, Ciroldi M, Azoulay E. Care at the end of life in critically ill patients: the European perspective. Curr Opin Crit Care 2006; 11:616-23. [PMID: 16292070 DOI: 10.1097/01.ccx.0000184299.91254.ff] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Care surrounding end-of-life has become a major topic in the intensive care medicine literature. Cultural and regional variations are associated with transatlantic debates about decisions to forego life-sustaining therapies and lead to recent international statements. The aim of this review is to provide insight into the decisions to forego life sustaining therapies and end-of-life care in Europe. RECENT FINDINGS Although decisions to forego life-sustaining therapies are increasingly made in European countries, frequency and characteristics of end-of-life care are still heterogeneous. Moreover, even though many determinants of these variations have been identified, epidemiologic and interventional studies still provide additional information. In agreement with public opinions, recent European laws have emphasized the patient's autonomy. In real life, advance care planning is rarely used. Decisions are often made by caregivers (physicians and nurses) or families, these latter being less involved than in North America. Not only ethic divergences between physicians but also cultural variations account for this disparity. SUMMARY To optimize end-of-life care in the intensive care unit, there is an urgent need for the development of palliative and multidisciplinary care in Europe. Furthermore, it highlights the need for culturally competent care, adapted to needs and values of every single patient and family. In addition, a lack of communication with families and within the medical team, an uninformed public about end-of-life issues, and insufficient training of intensive care unit staff are crucial barriers to end-of-life care development. Special awareness of professionals and innovative research are needed to promote a high-standard of end-of-life care in the intensive care unit.
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Affiliation(s)
- Thomas Fassier
- Medical Intensive Care Unit, Saint Louis Teaching Hospital and Paris 7 University, Paris, France
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81
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Wiegand DLM. Withdrawal of Life-Sustaining Therapy After Sudden, Unexpected Life-Threatening Illness or Injury: Interactions Between Patients’ Families, Healthcare Providers, and the Healthcare System. Am J Crit Care 2006. [DOI: 10.4037/ajcc2006.15.2.178] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background Withdrawal of life-sustaining therapy in intensive care units is increasing. Patients’ families are intimately involved in this process because the patients are usually unable to participate. Little is known about family members’ interactions with healthcare providers and the healthcare system during this process.• Objective To describe the interactions between patients’ family members, healthcare providers, and the healthcare system during withdrawal of life-sustaining therapy after a sudden, unexpected illness or injury.• Methods The investigation was part of a larger interpretative phenomenological study. Nineteen families (56 family members) who participated in the process of withdrawal of life-sustaining therapy for a family member were interviewed and observed. An inductive approach to data analysis was used to discover units of meaning, clusters, and categories.• Results The families’ experiences involved a variety of dimensions, including issues with healthcare providers (bonds and consistency with nurses and physicians, physicians’ presence, information, coordination of care, family meetings, sensitivity to time, and preparation for the dying process) and issues with the healthcare system (parking, struggles with finding privacy, and transfers of patients).• Conclusions Patients’ families need information, guidance, and support as the families participate in the process of withdrawal of life-sustaining therapy. The results of this study have important implications for clinical practice and future research.
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Affiliation(s)
- Debra Lynn-McHale Wiegand
- University of Pennsylvania, Philadelphia, Pa, and Yale University School of Nursing, New Haven, Conn (now at School of Nursing, University of Maryland, Baltimore, Md)
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82
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Fineberg IC. Preparing professionals for family conferences in palliative care: evaluation results of an interdisciplinary approach. J Palliat Med 2005; 8:857-66. [PMID: 16128661 DOI: 10.1089/jpm.2005.8.857] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patients, families, and health care professionals recognize the need for better communication in palliative and end-of-life care. Family conferences are a powerful clinical tool for communicating with patients and family members. Although family conferences are often used in medical care, few clinicians are prepared to conduct them effectively. An innovative palliative care educational model that included specific attention to family conferences was developed and evaluated. To intervene early in the process of professional socialization, the interactive and interdisciplinary training included medical and social work students. METHOD A quasi-experimental longitudinal design was employed to evaluate the educational intervention. Survey measures were administered before, immediately after, and three months after training. Questions addressed experience, education, and attitudes about family conferences. A standardized scale was used to measure change in students' confidence in their ability to lead family conferences. RESULTS For both professions, the intervention group demonstrated a significant increase in confidence in the ability to lead family conferences compared with the control group. Three-month follow-up data suggested that subjects in the intervention group maintained these gains. CONCLUSION This pilot intervention showed that an interdisciplinary educational approach improves confidence in the ability to lead family conferences when students are exposed early in the process of professional socialization. Early intervention increases the propensity and skills needed to conduct family conferences and advances communication in palliative care. Future research on interdisciplinary education should evaluate effects on clinical practice behaviors, satisfaction with communication and collaboration, and patients' and families' perceptions of quality of care.
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Affiliation(s)
- Iris Cohen Fineberg
- Division of General Internal Medicine and Health Services Research, University of California-Los Angeles, 911 Broxton Plaza, Los Angeles, CA 90095-1736, USA.
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83
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Boyle DK, Miller PA, Forbes-Thompson SA. Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes. Crit Care Nurs Q 2005; 28:302-16. [PMID: 16239819 DOI: 10.1097/00002727-200510000-00002] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Even though good communication among clinicians, patients, and family members is identified as the most important factor in end-of-life care in ICUs, it is the least accomplished. According to accumulated evidence, communication about end-of-life decisions in ICUs is difficult and flawed. Poor communication leaves clinicians and family members stressed and dissatisfied, as well as patients' wishes neglected. Conflict and anger both among clinicians and between clinicians and family members also result. Physicians and nurses lack communication skills, an essential element to achieve better outcomes at end of life. There is an emerging evidence base that proactive, multidisciplinary strategies such as formal and informal family meetings, daily team consensus procedures, palliative care team case finding, and ethics consultation improve communication about end-of-life decisions. Evidence suggests that improving end-of-life communication in ICUs can improve the quality of care by resulting in earlier transition to palliative care for patients who ultimately do not survive and by increasing family and clinician satisfaction. Both larger, randomized controlled trials and mixed methods designs are needed in future work. In addition, research to improve clinician communication skills and to assess the effects of organizational and unit context and culture on end-of-life outcomes is essential.
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Affiliation(s)
- Diane K Boyle
- School of Nursing, University of Kansas Medical Center, Kansas City, KS 66160, USA.
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84
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Abstract
There is a critical mismatch between available organs for transplant and acutely or critically ill patients with end-stage organ disease. Patients who may benefit from organ transplantation far outnumber available organs. The causes for this imbalance are multiple. One cause is family refusal to donate. A second cause is nonrecognition or delay in determination of brain death. A third cause is donor loss due to profound cardiopulmonary and metabolic instability consequent to brain-stem herniation and brain death. Family refusal may be addressed by education, public awareness, as well as close attention to social, cultural and ethical issues, and optimal communication with donor families. Brain death may be consequent to traumatic brain injury, ischemic versus hemorrhagic stroke, as well as massive cerebral anoxia/ischemic following cardiac arrest. Nonrecognition or delay in brain death determination may be addressed by clinician education and frequent clinical assessment to detect early stages of brain-stem herniation refractory to aggressive measures for control of intracranial pressure. Donor loss due to profound cardiopulmonary and metabolic instability may be addressed by aggressive, mechanism-based treatment for clinical instability based on affected body system, as well as measures to support metabolic activity at the cellular and tissue level in the brain-dead organ donor. This article explores cerebral physiology related to impending brain death and catastrophic intracranial pressure elevations. In addition, physiologic consequences of brain death are correlated with affected body systems and mechanism-based therapies to support organ function pending transplantation. Ethical/legal issues are explored as related to patient autonomy and optimal family outcomes. Effective family communication, astute clinical assessment, and optimal clinical management of the organ donor are illustrated using a case study approach, highlighting the role of the advanced practice nurse in donor management.
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Affiliation(s)
- Richard Arbour
- Medical Intensive Care Unit, Albert Einstein Healthcare Network, Philadelphia, PA 19141-3211, USA.
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85
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Casanueva Mateos L, Ruiz López P, Sánchez Díaz JI, Ramos Casado MV, Belda Hofheinz S, Llorente de la Fuente A, Mar Molinero F. Cuidados al final de la vida en la unidad de cuidados intensivos pediátrica. Revisión de la bibliografía. An Pediatr (Barc) 2005; 63:152-9. [PMID: 16045875 DOI: 10.1157/13077458] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION In the last few years, there has been growing concern in the literature about issues related to end-of-life care in pediatric intensive care units (PICUs), with special attention on the family/patient unit, communication, and a dignified death. OBJECTIVE To evaluate the experience and development of end-of-life care in PICUs through a literature review, by determining the type of studies that have been performed, their topics, the issues discussed, and their development in the last few years. MATERIAL AND METHODS Review of the medical literature in Medline and the database of the National Library of Medicine Gateway, using the key words from MeSH: "end of life", "pediatric intensive care", "critical care", "palliative care", "death", and "compassionate care". The earliest year of the search was 1990. The languages selected were English and Spanish. Inclusion criteria were the relationship with the topic to be studied, excluding articles with no abstract. Additional searches were made of references in selected articles. RESULTS Eighty-one articles were retrieved from the initial search. Of these, 43 were selected as the most relevant investigations in end-of-life care in ICUs and 18 placed special emphasis on the PICU. More than half of the articles (62 %) were reviews and the remaining articles were descriptive or observational studies. The number of publications increased after 1995. Most of the studies were performed in the USA or Canada and only three studies were performed in Spain. CONCLUSIONS In the last few years, several studies have been performed that reveal increasing concern about limits to therapeutic intervention and the need to improve end-of-life care in the PICU setting.
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Affiliation(s)
- L Casanueva Mateos
- Unidad de Cuidados Intensivos Pediátricos, Hospital 12 de Octubre, Madrid, España.
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86
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Abstract
Palliative care for the critically ill has become an increasingly important component of care in the SICU. As the population ages, medical technology continues to offer new treatments that can prolong life, and more and more Americans die in the hospital in critical care settings, the appropriate management of the end-of-life must be part of the clinical expertise of surgeons and intensivists. Part of this expertise must include the components of palliative care (eg, pain and symptom management, psychosocial support, communication skills, shared decision-making) and specialized areas of withdrawal and withholding of life support. Integrating palliative care expertise into the SICU is not straightforward; understanding when and how to make the transition from curative to palliative care can be fraught with uncertainty regarding prognosis and patient preferences. Attention to the principles of good pain management, communication with patient and family, and discussion of goals of care are not just for patients who are at the end-of-life, but are appropriate care for all critically ill patients, regardless of prognosis. In this framework, "intensive care"encompasses palliative and curative care.
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Affiliation(s)
- Anne Charlotte Mosenthal
- Division Surgical Critical Care, New Jersey Medical School, University of Medicine & Dentistry of New Jersey-University Hospital, 150 Bergen Street, Mezzanine 233, Newark, NJ 07103, USA.
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87
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Evans W. Bibliography. HEALTH COMMUNICATION 2005; 17:323-327. [PMID: 15855076 DOI: 10.1207/s15327027hc1703_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- William Evans
- Institute for Communication and Information Research, University of Alabama, Tuscaloosa, AL 35487-0172, USA.
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