Intensive care unit cultures and end-of-life decision making

Withholding or withdrawing therapy in Danish regional ICUs: frequency, patient characteristics and decision process

BACKGROUND

New options for intensive therapy have increased the necessity of considering withholding or withdrawing therapy at intensive care units (ICUs), but the practice varies according to regional and cultural differences. The aim of this study was to investigate the frequency of withholding or withdrawing therapy in two secondary Danish ICUs, to describe the characteristics of patients in whom such decisions were made and to examine the existing documentation of the decision process.

METHODS

A retrospective review of hospital records for all patients admitted to two regional Danish ICUs in 2008. The records were searched for all information regarding deliberations or decisions on withholding or withdrawing therapy.

RESULTS

Of 1665 patients admitted to the ICUs, 176 patients (10.6%) died; of these, 34 (19.3%) died while still receiving full active therapy, 25 (14.2%) died after therapy was withheld and 117 (66.5%) died after therapy was withdrawn. An additional 88 patients (5.3%) were discharged alive with therapy either withheld or withdrawn. The patients who died had higher severity scores, were older and were more likely to be men than those who were discharged with full therapy. The main reasons for withholding or withdrawing therapy were prognosis for acute illness and the deemed futility of therapy. The median time from admission to a decision on withholding or withdrawing therapy was 1.4 days.

CONCLUSION

Withholding or withdrawing therapy is common in Danish ICUs but more research is needed to explore the different aspects of withholding or withdrawing therapy in Danish ICUs.

Conceptual framework for the study of parental end-of-life decision making in pediatric blood and marrow transplantation

PURPOSE/OBJECTIVES

To describe a conceptual framework that will facilitate research and practice concerning parental end-of-life decision making in pediatric blood and marrow transplantation (BMT).

DATA SOURCES

A review of relevant literature from Ovid, CINAHL, EBSCO, MEDLINE, PsycINFO, and various sociology and theology databases was combined with experiential knowledge.

DATA SYNTHESIS

The method of concept and theory synthesis and derivation as described by Walker and Avant was used in the development of this framework.

CONCLUSIONS

Use of the proposed conceptual framework is expected to provide the organization necessary for thinking, observation, and interpretation of parental end-of-life decision making in pediatric BMT.

IMPLICATIONS FOR NURSING

The ability to describe the process of parental end-of-life decision making in pediatric BMT will help nurses to provide appropriate counseling, education, and support for these children and their families at the end of life. In addition, the process will help nurses to promote the well-being of the children's families after end of life.

End of life management of adult patients in an Australian metropolitan intensive care unit: A retrospective observational study

BACKGROUND

Death in the intensive care unit is often predictable. End of life management is often discussed and initiated when futility of care appears evident. Respect for patients wishes, dignity in death, and family involvement in the decision-making process is optimal. This goal may often be elusive.

PURPOSE

Our purpose was to review the end of life processes and family involvement within our Unit.

METHODS

We conducted a chart audit of all deaths in our 10 bed Unit over a 12-month period, reviewing patient demographics, diagnosis on admission, patient acuity, expectation of death and not-for-resuscitation status. Discussions with the family, treatments withheld and withdrawn and extubation practices were documented. The presence of family or next-of-kin at the time of death, the time to death after withdrawal of therapy and family concerns were recorded.

RESULTS

There were 70 patients with a mean age of 69 years. Death was expected in 60 patients (86%) and not-for-resuscitation was documented in 58 cases (85%). Family discussions were held in 63 cases (90%) and treatment was withdrawn in 34 deaths (49%). After withdrawal of therapies, 31 patients (44%) died within 6h. Ventilatory support was withdrawn in 24 cases (36%). Family members were present at the time of death in 46 cases (66%). Family concerns were documented about the end of life care in only 1 case (1.4%).

CONCLUSION

Our data suggests that death in our Unit was often predictable and that end of life management was a consultative process.

Nine structures and leadership practices essential for a magnetic (healthy) work environment

Improving clinical nurse work environments is a major challenge faced by nurse executives today. To meet this challenge, nurse leaders must implement the "right" structures and best leadership practices so that clinical nurses can engage in the work processes and relationships that are empirically linked to quality patient outcomes. What are these "right" structures and best leadership practices? Meta-analyses of 2 sets of publications were used to identify organizational structures and best leadership practices essential to a healthy work environment, that is, a work environment that enables them to engage in the work processes and relationships needed for quality patient care outcomes. The first set was 12 publications from 7 professional organizations/regulatory bodies that advocated forces, hallmarks, and standards for a healthy work environment. The second set was 18 publications from the Essentials of Magnetism structure-identification studies, in which the aggregated results from 1300 interviews with staff nurse, manager, and physician "experts" were compared with the agency results. Broadening the categories and final aggregation yielded the 9 most important and influential structures essential to a quality work environment. Suggestions for implementing these structures are provided.

Life support decision making in critical care: Identifying and appraising the qualitative research evidence

OBJECTIVE

The objective of this study is to identify and appraise qualitative research evidence on the experience of making life-support decisions in critical care.

DATA SOURCES

In six databases and supplementary sources, we sought original research published from January 1990 through June 2008 reporting qualitative empirical studies of the experience of life-support decision making in critical care settings.

STUDY SELECTION

Fifty-three journal articles and monographs were included. Of these, 25 reported prospective studies and 28 reported retrospective studies.

DATA EXTRACTION

We abstracted methodologic characteristics relevant to the basic critical appraisal of qualitative research (prospective data collection, ethics approval, purposive sampling, iterative data collection and analysis, and any method to corroborate findings).

DATA SYNTHESIS

Qualitative research traditions represented include grounded theory (n = 15, 28%), ethnography or naturalistic methods (n = 15, 28%), phenomenology (n = 9, 17%), and other or unspecified approaches (n = 14, 26%). All 53 documents describe the research setting; 97% indicate purposive sampling of participants. Studies vary in their capture of multidisciplinary clinician and family perspectives. Thirty-one (58%) report research ethics board review. Only 49% report iterative data collection and analysis, and eight documents (15%) describe an analytically driven stopping point for data collection. Thirty-two documents (60%) indicated a method for corroborating findings.

CONCLUSIONS

Qualitative evidence often appears outside of clinical journals, with most research from the United States. Prospective, observation-based studies follow life-support decision making directly. These involve a variety of participants and yield important insights into interactions, communication, and dynamics. Retrospective, interview-based studies lack this direct engagement, but focus on the recollections of fewer types of participants (particularly patients and physicians), and typically address specific issues (communication and stress). Both designs can provide useful reflections for improving care. Given the diversity of qualitative research in critical care, room for improvement exists regarding both the quality and transparency of reported methodology.

Nursing Roles in End-of-Life Decision Making in Critical Care Settings

This study used a grounded theory approach to formulate a conceptual framework of the nursing role in end-of-life decision making in a critical care setting. Fourteen nurses from an intensive care unit and cardio-respiratory care unit were interviewed. The core concept, Supporting the Journey, became evident in four major themes: Being There, A Voice to Speak Up, Enable Coming to Terms, and Helping to Let Go. Nurses described being present with patients and families to validate feelings and give emotional support. Nursing work, while bridging the journey between life and death, imparted strength and resilience and helped overcome barriers to ensure that patients received holistic care. The conceptual framework challenges nurses to be present with patients and families at the end of life, clarify and interpret information, and help families come to terms with end-of-life decisions and release their loved ones.