Intensive care nurses' experiences with end-of-life care

Respect in critical care: a foundational ethical principle

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.

[Care to the end-stage patient: help and obstacles perceived by Intensive Care nurses]

BACKGROUND

The Intensive Care Unit (UCI) environment is not the most appropriate for the development of the end-of-life process, due to the fact that ICU is a hi-tech setting and its focus is on curing and giving life support, rather than delivering palliative care to patients.

AIMS

To investigate supportive behaviours and obstacles, and the nurses' demographic characteristics.

METHOD

A descriptive correlational design was used in five tertiary Spanish hospitals. A convenience sample included 151 critical care nurses. A self-administered anonymous questionnaire (Beckstrand and Kirchhoff, 2005) was used to investigate supportive behaviours and obstacles perceived by nurses providing end-of-life care, in a scale from 0 to 5 (O = not help/obstacle; 5 = main help/obstacle). Some demographic data of the sample were also collected.

FINDINGS

Nurses mean age was 35 (min. 22-max. 57; SD = 7,6) and had an average of 9,2 (min. 1-max. 30; SD = 6,9) years of experience working in ICU. Physicians agreeing on direction of patient care was perceived as the most supportive item (x = 4.46); whereas ethics committee constantly involved in the unit as the least supportive one (x = 2.93). The main obstacle for nurses was patient having pain that is difficult to control or alleviate (x = 4.38), and nurses knowing poor prognosis before family was seen as the less important obstacle (x = 1.37) Statistically significant correlations were found between nurses age and years of experience in ICU and their perception of some helps/obstacles. Statistically significant differences were found between nurses with postgraduate education in intensive care and those without it and their perception of some helps/obstacles.

CONCLUSIONS

Intensive care nurses perceive adequate patients' pain management, agreement between health professionals on decision-making, and facilitating a comfortable environment for patients and families, during the whole end-of-life process as a priority.

Examining Older Adults’ Perceptions of Health Care Providers: Identifying Important Aspects of Older Adults’ Relationships With Physicians and Nurses

This article describes older adults' conversations about their relationships with health care providers. Focus group participants (N = 23) were from three ethnic groups (Black, White, and Hispanic) and ages 53 to 92. All but three of the participants were women. Content analysis revealed an overarching theme of genuine caring and three sub-themes: interest in patients' well-being, respectful dialogue, and sharing of information. Older adults' perceptions of genuine caring by physicians and nurses did not differ by ethnicity. Older adults want to engage in a caring, respectful, and educational relationship with their health care providers, which is consistent with fundamental professional values.

Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate

OBJECTIVE

To explore registered nurses' and attending physicians' perspectives on caring for dying patients in intensive care units (ICUs), with particular attention to the relationships among moral distress, ethical climate, physician/nurse collaboration, and satisfaction with quality of care.

DESIGN

Descriptive pilot study using a survey design.

SETTING

Fourteen ICUs in two institutions in different regions of Virginia.

SUBJECTS

Twenty-nine attending physicians who admitted patients to the ICUs and 196 registered nurses engaged in direct patient care.

INTERVENTIONS

Survey questionnaire.

MEASUREMENTS AND MAIN RESULTS

At the first site, registered nurses reported lower collaboration (p<.001), higher moral distress (p<.001), a more negative ethical environment (p<.001), and less satisfaction with quality of care (p=.005) than did attending physicians. The highest moral distress situations for both registered nurses and physicians involved those situations in which caregivers felt pressured to continue unwarranted aggressive treatment. Nurses perceived distressing situations occurring more frequently than did physicians. At the second site, 45% of the registered nurses surveyed reported having left or considered leaving a position because of moral distress. For physicians, collaboration related to satisfaction with quality of care (p<.001) and ethical environment (p=.004); for nurses, collaboration was related to satisfaction (p<.001) and ethical climate (p<.001) at both sites and negatively related to moral distress at site 2 (p=.05). Overall, registered nurses with higher moral distress scores had lower satisfaction with quality of care (p<.001), lower perception of ethical environment (p<.001), and lower perception of collaboration (p<.001).

CONCLUSIONS

Registered nurses experienced more moral distress and lower collaboration than physicians, they perceived their ethical environment as more negative, and they were less satisfied with the quality of care provided on their units than were physicians. Provider assessments of quality of care were strongly related to perception of collaboration. Improving the ethical climate in ICUs through explicit discussions of moral distress, recognition of differences in nurse/physician values, and improving collaboration may mitigate frustration arising from differences in perspective.

A good death

The Institute of Medicine defines a good death a “one that is free from avoidable death and suffering for patients, families and caregivers in general accordance with the patients’ and families’ wishes.”. The current system creates barriers to reducing the stress and suffering that accompany a patient’s end of life. Data and eHealth technology, if it were more accessible, could help patients, families, and caregivers to cope with end of life issues.

Understanding the Moral Distress of Nurses Witnessing Medically Futile Care

PURPOSE/OBJECTIVES

To explore the topic of moral distress in nurses related to witnessing futile care.

DATA SOURCES

Literature related to moral distress and futility; analysis of narratives written by 108 nurses attending one of two national continuing education courses on end-of-life care regarding their experiences in the area.

DATA SYNTHESIS

Nurses were invited to share a clinical situation in which they experienced moral distress related to a patient receiving care that they considered futile. Nurses described clinical situations across care settings, with the most common conflict being that aggressive care denies palliative care. Conflicts regarding code status, life support, and nutrition also were common. Patients with cancer were involved quite often, second only to geriatric patients and patients with dementia. The instances created strong emotional responses from nurses, including feeling the need for patient advocacy and that futile care was violent and cruel. Important spiritual and religious factors were cited as influencing the clinical experiences.

CONCLUSIONS

Instances of futile care evoke strong emotional responses from nurses, and nurses require support in dealing with their distress.

IMPLICATIONS FOR NURSING

The ethical dilemma of futile care is complex. Additional research and support are needed for patients, families, and nurses.

Measuring Intensive Care Nurses’ Perspectives on Family-Centered End-of-Life Care: Evaluation of 3 Questionnaires

• Background Attempts to improve end-of-life care increasingly focus on family-centered care, but few validated assessment tools exist.

• Objectives To evaluate 3 new short questionnaires measuring nurses’ perspectives on family-centered end-of-life care in the intensive care unit and to show the usefulness of the questionnaires.

• Methods Principal components analysis of data from 141 critical care nurses evaluating care given to families of 218 patients was used to develop domain scores for number of nursing activities with each family, number of barriers experienced, and nurses’ satisfaction that the family’s needs were met. Random effects models were used to test associations between critical care processes and outcome.

• Results Nursing activities fell into 2 domains: general and culture-related communication/support. Barriers consisted of 2 domains: patient/family barriers and system/team barriers. Meeting the needs of patients’ families represented a single dimension. In a path model based on domain scores, general activities had significant associations with both nurse communication and meeting families’ needs; patient/family barriers, with nurse communication; and nurse and physician communication, with meeting families’ needs. In a path model based on total activities and barriers scores, total activities and total barriers had significant associations with nurse communication ratings and meeting families’ needs. Patients’ and nurses’ characteristics were not significant independent predictors of meeting the needs of patients’ families.

• Conclusions The 3 questionnaires provide a consistent, valid picture of nurses’ perspectives on family-centered critical care and may be useful in evaluating family care processes and outcomes and in targeting areas for improvement.

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

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.

Nurses' perceptions of quality end-of-life care on an acute medical ward

AIM

This paper reports the findings of a study that generated a conceptual model of the nursing behaviours and social processes inherent in the provision of quality end-of-life care from the perspective of nurses working in an acute care setting.

BACKGROUND

The majority of research examining the issue of quality end-of-life care has focused on the perspectives of patients, family members and physicians. The perspective of nurses has generally received minimal research attention, with the exception of those working within palliative or critical care. The vast majority of hospitalized patients, however, continue to be cared for and die on medical units. To date, little research has been conducted examining definitions and determinants of quality end-of-life care from the perspective of nurses working in acute adult medical settings.

METHOD

Grounded theory method was used in this study of 10 nurses working on acute medical units at two tertiary university-affiliated hospitals in central Canada. Data were collected during 2002 by interview and participant observation.

FINDINGS

The basic social problem uncovered in the data was that of nurses striving to provide high quality end-of-life care on an acute medical unit while being pulled in all directions. The unifying theme of 'Creating a haven for safe passage' integrated the major sub-processes into the key analytic model in this study. 'Creating a haven for safe passage' represents a continuum of behaviours and strategies, and includes the sub-processes of 'facilitating and maintain a lane change'; 'getting what's needed'; 'being there'; and 'manipulating the care environment'.

CONCLUSION

The ability of nurses to provide quality end-of-life care on an acute medical unit is a complex process involving many factors related to the patient, family, healthcare providers and the context in which the provision of end-of-life care takes place.

Caring for Dying Patients and those Facing Death in an Acute-Care Hospital in Singapore: A Nurse’s Perspective

Nurses are at the forefront of caring for dying patients in hospices, nursing homes, acute-care hospitals, and patients' homes. This study was conducted to explore the emotional and practical experience as well as attitudes of nurses caring for the dying and the deceased in an acute-care hospital in Singapore. The authors explored differences in opinion among the various ethnic groups (Malay, Chinese, Indian, Filipino) that make up the nurse population in this particular hospital. A structured questionnaire was self-administered by the participants to explore nurses' views, opinions, and experiences in caring for dying patients from a quantitative aspect. It specifically addressed attitudinal, ethical, and communicational issues involved in caring for dying patients. Where applicable, a Likert scale ranging from Always to Never or from Strongly Agree to Strongly Disagree was used. One hundred and eighty of 246 questionnaires were returned (73%). Most respondents never or only occasionally felt uncomfortable caring for dying patients, and felt it reminded them of their own mortality, made them treasure life more, and made them ask questions about life and death. In this descriptive study, some difference in attitudes and views among the various ethnic groups was observed.

Providing a “Good Death”: Critical Care Nurses’ Suggestions for Improving End-of-Life Care

• Background Providing appropriate end-of-life care has become a primary concern of nurses and the public. The highly technological critical care environment may not facilitate such care.

• Objective To collect suggestions from critical care nurses for improving end-of-life care in intensive care units.

• Methods A geographically dispersed, random sample of 1409 members of the American Association of Critical-Care Nurses was sent a 72-item survey on perceptions of end-of life care. The survey included a request for suggestions on ways to improve end-of life care.

• Results Of the 861 critical care nurses who responded to the survey, 485 offered 530 suggestions for improving end-of-life care. Providing a “good death” was the major theme; specific suggestions included ways to help ensure death with dignity and peace. Barriers to providing good deaths included nursing time constraints, staffing patterns, communication challenges, and treatment decisions that were based on physicians’ rather than patients’ needs. Suggestions for providing a good death included facilitating dying with dignity; not allowing patients to be alone while dying; managing patients’ pain and discomfort; knowing, and then following, patients’ wishes for end-of-life care; promoting earlier cessation of treatment or not initiating aggressive treatment at all; and communicating effectively as a health-care team. Educational initiatives for professionals and the public were also suggested.

• Conclusions Implementation of specific suggestions provided by experienced critical care nurses might increase the quality of end-of-life care, facilitating a good death for intensive care patients.

Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes

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.

Barriers to communication regarding end-of-life care: perspectives of care providers

OBJECTIVE

Communication regarding end-of-life care is frequently perceived as suboptimal, despite the intent of both health care providers and patients. We interviewed health care providers to determine their perspective regarding these barriers to communication.

MATERIALS AND METHODS

Eleven focus groups with a total of 10 attending physicians, 24 residents, and 33 nurses were convened to explore barriers to end-of-life discussions on the Internal Medicine service at a 600-bed tertiary care hospital in Toronto, Canada. An interview schedule was designed to elicit information regarding the process of end-of-life discussions, barriers to these discussions, and possible interventions for limiting such barriers. Transcripts were qualitatively analyzed by 6 raters who independently identified "themes." Themes were refined using the Delphi technique and classified under broader "categories."

RESULTS

Four main categories of barriers emerged, relating to (1) patients, (2) the health care system, (3) health care providers, and (4) the nature of this dialogue. Attending physicians and residents most frequently identified patient-related factors as barriers to discussions, followed by system, dialogue, and provider barriers (43%, 39%, 10%, and 8%, respectively, for attending physicians; 40%, 34%, 13%, and 13%, respectively, for residents). Nurses similarly identified patient-related and system barriers most frequently, but provider barriers were discussed more often than dialogue barriers (46%, 28%, 22%, and 4%, respectively).

CONCLUSIONS

Attending physicians, residents, and nurses perceive the recipients of their care, and the system within which they provide this care, to be the major source of barriers to communication regarding end-of-life care. This finding may impact on the effectiveness of quality-improvement initiatives in end-of-life care.

Providing End-of-Life Care to Patients: Critical Care Nurses’ Perceived Obstacles and Supportive Behaviors

• Background Critical care nurses care for dying patients daily. The process of dying in an intensive care unit is complicated, and research on specific obstacles that impede delivery of end-of-life care and/or supportive behaviors that help in delivery of end-of-life care is limited.

• Objective To measure critical care nurses’ perceptions of the intensity and frequency of occurrence of (1) obstacles to providing end-of-life care and (2) supportive behaviors that help in providing end-of-life care in the intensive care unit.

• Methods An experimental, posttest-only, control-group design was used. A national, geographically dispersed, random sample of members of the American Association of Critical-Care Nurses was surveyed.

• Results The response rate was 61.3%, 864 usable responses from 1409 eligible respondents. The highest scoring obstacles were frequent telephone calls from patients’ family members for information, patients’ families who did not understand the term lifesaving measures, and physicians disagreeing about the direction of a dying patient’s care. The highest scoring supportive behaviors were allowing patients’ family members adequate time alone with patients after death, providing peaceful and dignified bedside scenes after death, and teaching patients’ families how to act around a dying patient.

• Conclusions The biggest obstacles to appropriate end-of-life care in the intensive care unit are behaviors of patients’ families that remove nurses from caring for patients, behaviors that prolong patients’ suffering or cause patients pain, and physicians’ disagreement about the plan of care.

Cuidados al final de la vida en la unidad de cuidados intensivos pediátrica. Revisión de la bibliografía

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.

An insight into Australian nurses’ experience of withdrawal/withholding of treatment in the ICU

BACKGROUND

The success of biotechnology has created moral and ethical dilemmas concerning end-of-life care in the Intensive Care Unit (ICU). Whilst the competent individual has the right to refuse or embrace treatment, ICU patients are rarely able to exercise this right. Thus, decision-making is left to medical professionals and family/significant others.

AIM

This study aimed to explore the lived experience of ICU nurses caring for clients having treatment withdrawn or withheld, and increase awareness and understanding of this experience amongst other health professionals.

METHODS

Van Manens' (1990) phenomenological framework formed the basis of this study as it provided an in-depth insight into the human experience. A convenience sample of ten ICU Nurses participated in the study. Conversations were transcribed verbatim and analysed using a process of thematic analysis.

RESULTS

Five major themes emerged during the analysis. These were: (1) comfort and care, (2) tension and conflict, (3) do no harm, (4) nurse-family relationships and (5) invisibility of grief and suffering.

CONCLUSION

The experience of providing care for the adult having treatment withdrawn or withheld in the ICU represents a significant personal and professional struggle. Improvements in communication between health professionals, debriefing and education about the process of withdrawing or withholding treatment would be beneficial to both staff and families and has the potential to improve patient care and reduce burden on nurses.

Caring for the family of the critically ill patient

Family's needs and considerations are an essential component of intensive care unit (ICU) care. Family satisfaction is related to clinician communication and decision making. Indeed, timely, honest communication is vital to the psychosocial health and satisfaction of the family. Conflict often arises within the family and between the family and the clinicians, over decision making. Again, good communication skills are critical to family satisfaction with decision making and comfort with the care received. Family members have numerous psychosocial changes, and may experience depression,anxiety, or anticipatory grief while their family member is dying in the ICU. Awareness of these conditions, providing support to the families, and allowing family access to the dying individual can assist with meeting the family's desire to see their family member have a peaceful death.

Trauma and tribulation: the experiences and attitudes of operating room nurses working with organ donors

BACKGROUND

In the past two decades, significant medical advances have resulted in remarkable success and survival rates for organ recipients. However, the rates of donation have not kept pace with the demand, resulting in a critical shortage of available healthy organs. It has been suggested that the attitudes of medical personnel towards organ retrieval is a key success factor in improving organ donation. Yet there is evidence that those closest to the process of procurement are the most negative.

AIMS AND OBJECTIVES

This study sought to examine the attitudes towards organ donation of operating room nurses and their experiences of participating in the procurement of organs for transplant, in order to unravel factors that contribute to their attitudes.

METHODS

This study relied upon in-depth qualitative interviews with 14 operating room nurses who participated in organ procurement in a large urban trauma centre.

RESULTS

The results of this study suggest that the process of organ procurement is highly stressful and raises many concerns for operating room nurses. Factors, which added to participants' distress, include organizational factors such as strained relationships within surgical teams, concerns about the dignity of the patient and the well-being of the family and exposure to death and trauma.

CONCLUSIONS

Experiences of nurses participating in surgical removal of organs for transplantation resulted in personal feelings of distress and negative attitudes to the issue of organ donation which may be transmitted to others and undermine organ procurement efforts.

RELEVANCE TO CLINICAL PRACTICE

The concerns of these vital members of the organ procurement team should be heeded and actions taken to reduce their distress and improve their attitudes towards donation.

Integration of critical care and palliative care at end of life

End-of-life care in the critical care environment suffers from a lack of clarity and uncertainty. Critical care nurses may often feel torn between wanting to do everything possible to sustain a patient's life and wanting to do what is in the patient's best interests. Reframing the focus of care from cure to comfort can be an uncomfortable shift for nurses, who may not be in control of when the change of goals takes place. Good end-of-life care should be a core competency for all nurses and it is our responsibility to ensure that decisions to forgo life-sustaining treatment in critical care are appropriate and timely. Futility, conflict and resources all factor in such decisions. Nurses must ensure the transition from cure to comfort does not emphasize a dichotomy between palliative care and critical care but instead focuses on the provision of the best possible end-of-life care.

Analysis of end-of-life content in critical care nursing textbooks

Nurses have identified a need for improving their knowledge and skills in providing end-of-life care. Critical care nursing textbooks can serve as an important source of information on end-of-life care for critical care nurses. Hence, an analysis of end-of-life content in 14 critical care nursing textbooks was conducted. Critical care nursing textbooks used for review were published in 1995 or later and identified from the libraries at the University of Wisconsin-Madison and Brigham Young University. The end-of-life content areas identified by the American Association of Colleges of Nursing (AACN), under which the AACN end-of-life competencies for undergraduate nursing students can be taught, were used as a framework for assessing the presence or absence of end-of-life content in the textbooks. When end-of-life content was present, two reviewers judged whether the information was helpful. Four additional end-of-life content areas were identified in some textbooks during the study, and reviewers also judged whether these were helpful. None of the textbooks had end-of-life content in all the content areas used for the analysis. Three textbooks did not contain any end-of-life content.

Life Support Withdrawal: Communication and Conflict

• Background Skillful communication between and among clinicians and patients’ families at the patients’ end of life is essential for decision making. Yet communication can be particularly difficult during stressful situations such as when a family member is critically ill. This is especially the case when families are faced with choices about forgoing life-sustaining treatment.

• Objectives Data from a larger study on treatment withdrawal (n = 74) indicated that the family members (n = 20) of some patients experienced conflict with clinicians during decision making. This secondary analysis was done to examine and describe the communication difficulties from the perspectives of patients’ family members who experienced conflict with clinicians about the care and treatment of the patients during withdrawal of life support.

• Methods A qualitative descriptive analysis of family members (n = 20, representing 12 decedents) who experienced conflict.

• Results Families described several unmet communication needs during the often rapid shift from aggressive treatment to palliative care. These needs included the need for timely information, the need for honesty, the need for clinicians to be clear, the need for clinicians to be informed, and the need for clinicians to listen.

• Conclusions Although family members who experienced conflict were in the minority of the larger study sample, their concerns and needs are important for clinicians to examine. Paying careful attention to these communication needs could reduce the occurrence of conflict between clinicians and patients’ families in caring for dying patients and reduce stress for all involved.

Improving Family Communications at the End of Life: Implications for Length of Stay in the Intensive Care Unit and Resource Use

• Background Inadequate communication persists between healthcare professionals and patients and patients’ families in intensive care units. Unwanted or ineffective treatments can occur when patients’ goals of care are unknown or not honored, increasing costs and care. Having the primary physician provide medical information and then having a physician and clinical nurse specialist team improve opportunities for patients and their families to process that information could improve the situation. This model has not been tested for its effect on patients’ outcomes and resource utilization.

• Objectives To evaluate the effect of a communication team that included a physician and a clinical nurse specialist on length of stay and costs for patients near the end of life in the intensive care unit.

• Methods During a 1-year period, patients judged to be at high risk for death (N = 151) were divided into 2 groups: 43 patients who were cared for by the medical director teamed with a clinical nurse specialist and 108 patients who received standard care, provided by an attending physician.

• Results Compared with the control group, patients in the intervention group had significantly shorter stays in both the intensive care unit (6.1 vs 9.5 days) and the hospital (11.3 vs 16.4 days) and had lower fixed ($15 559 vs $24 080) and variable ($5087 vs $8035) costs.

• Conclusions Use of a physician and a clinical nurse specialist focused on improving communication with patients and patients’ families reduced lengths of stay and resource utilization.

ICU nurses' preparation of families for death of patients following withdrawal of ventilator support

Intensive care unit nurses were asked how they prepared families for the death of their patient following withdrawal of mechanical ventilation. Forty-three descriptors were identified, of which 67.5% (n = 29) were "physical sensations and symptoms." Less frequently mentioned features of Self-Regulation Theory were temporal characteristics, environmental features, and causes of these signs. Eight descriptors mentioned by more than 50% of nurses were skin color changes (74%), skin temperature changes (74%), varying levels of consciousness (74%), effort with breathing (71%), variable timeframe to death (68%), breathing pattern (65%), sound during breathing (61%), and loss of bowel control/incontinence (52%).

The role of the critical care nurse in the assessment and management of the patient with severe sepsis

Sepsis with acute organ dysfunction is common, frequently fatal, and expensive. The critical care nurse is involved in the continuous bedside care of the critically ill patient; consequently, he or she has the opportunity to prevent sepsis through infection control practices and general nursing care, to identify patients at risk for the disease, to monitor these patients for the clinical signs of sepsis, and to detect developing organ dysfunction as a manifestation of severe sepsis. In addition, the nurse is responsible for monitoring the patient's response to organ support measures and specific antisepsis interventions. The role of the critical care nurse in the assessment and management of severe sepsis is significant and can greatly improve outcomes for the patient with this disease. Drotrecogin alfa (activated) is a promising new therapy in the treatment of severe sepsis. Nurses caring for patients with this disease need to understand the issues related to the administration of drotrecogin alfa (activated) and the monitoring of patients receiving this drug to promote optimal and appropriate use of this innovative therapy.

Cardiorespiratory Nurses’ Perceptions of Palliative Care in Nonmalignant Disease: Data for the Development of Clinical Practice

Nurses lack a comprehensive body of scientific knowledge to guide the palliative care of patients with nonmalignant conditions. Current knowledge and practice reveal that nurses in many instances are not well prepared to deal with death and dying. Focus groups were used in an exploratory study to examine the perceptions of palliative care among cardiorespiratory nurses (n = 35). Content analysis was used to reveal themes in the data. Four major themes were found: (1) searching for structure and meaning in the dying experience of patients with chronic disease, (2) lack of a treatment plan and a lack of planning and negotiation, (3) discomfort in dealing with death and dying, and (4) lack of awareness of palliative care philosophies and resources. The information derived from this sample of cardiorespiratory nurses represents a complex interplay between personal, professional, and organizational perspectives on the role of palliative care in cardiorespiratory disease. The results of the study suggest a need for nurses to be equipped on both an intellectual and a practical level about the concept of palliative care in nonmalignant disease.

Palliative care services

This article presents a program developed at one facility to help provide palliative care services to patients in the intensive care units.

The nurse's role in end-of-life decision-making for patients and families

This article discusses some of the cultural changes required for organizations to build systems that move beyond mere completion of the advance directive to advance care planning that affects end-of-life decision-making. It specifically describes one organization's educational approach to clarifying the role of the nurse as patient advocate within these cultural changes and suggests strategies to help the nurse gain necessary competence in end-of-life decision-making.

Promoting a peaceful death in the ICU

Care for the dying ICU patient and family should be inclusive of respect for their goals, preferences. and choices. Care should be comprehensive, inclusive of all the patient domains (physical, psychosocial and, spiritual), and inclusive of all the specialties and disciplines that can be helpful at this complex time. The families' concerns should be acknowledged and support given. Our ICUs need to develop supportive environments for those dying patients who stay in the unit. Quality improvement and ongoing evaluation will provide avenues of change for care of this special group of patients and families.

The Vortex: Families’ Experiences With Death in the Intensive Care Unit

• Background Lack of communication from healthcare providers contributes to the anxiety and distress reported by patients’ families after a patient’s death in the intensive care unit.

• Objective To obtain a detailed picture of the experiences of family members during the hospitalization and death of a loved one in the intensive care unit.

• Methods A qualitative study with 4 focus groups was used. All eligible family members from 8 intensive care units were contacted by telephone; 8 members agreed to participate.

• Results The experiences of the family members resembled a vortex: a downward spiral of prognoses, difficult decisions, feelings of inadequacy, and eventual loss despite the members’ best efforts, and perhaps no good-byes. Communication, or its lack, was a consistent theme. The participants relied on nurses to keep informed about the patients’ condition and reactions. Although some participants were satisfied with this information, they wished for more detailed explanations of procedures and consequences. Those family members who thought that the best possible outcome had been achieved had had a physician available to them, options for treatment presented and discussed, and family decisions honored.

• Conclusions Uncertainty about the prognosis of the patient, decisions that families make before a terminal condition, what to expect during dying, and the extent of a patient’s suffering pervade families’ end-of-life experiences in the intensive care unit. Families’ information about the patient is often lacking or inadequate. The best antidote for families’ uncertainty is effective communication.

Synergizing acute care and palliative care to optimise nursing care in end-stage cardiorespiratory disease

Advances in the practice of medicine and nursing science have increased survival for patients with chronic cardiorespiratory disease. Parallel to this positive outcome is a societal expectation of longevity and cure of disease. Chronic disease and the inevitability of death creates a dilemma, more than ever before, for the health care professional, who is committed to the delivery of quality care to patients and their families. The appropriate time for broaching the issue of dying and determining when palliative care is required is problematic. Dilemmas occur with a perceived dissonance between acute and palliative care and difficulties in determining prognosis. Palliative care must be integrated within the health care continuum, rather than being a discrete entity at the end of life, in order to achieve optimal patient outcomes. Anecdotally, acute and critical care nurses experience frustration from the tensions that arise between acute and palliative care philosophies. Many clinicians are concerned that patients are denied a good death and yet the moment when care should be oriented toward palliation rather than aggressive management is usually unclear. Clearly this has implications for the type and quality of care that patients receive. This paper provides a review of the extant literature and identifies issues in the end of life care for patients with chronic cardiorespiratory diseases within acute and critical care environments. Issues for refinement of acute and critical care nursing practice and research priorities are identified to create a synergy between these philosophical perspectives.

Intensive care nurses' experiences of caring for dying patients: a phenomenological study

The experience of nurses working in end-of-life care, particularly those caring for cancer patients in the hospice setting, have been well researched. Yet despite the fact that intensive care units (ICUs) are frequently the site of patient death, studies of the nurses working in these units are uncommon. This study was designed to provide qualitative data to explore the experiences of intensive care nurses caring for patients who are dying. Semi-structured interviews were conducted with ten nurses who had experience of caring for dying patients in ICUs in two teaching hospitals in Taiwan. Data were analysed using a phenomenological descriptive approach. Participants' descriptions revealed the following core themes: considering nurses' attitudes to caring for the dying, stressors associated with this care and coping strategies that intensive care nurses adopt. The study concludes that education for ICU nurses must address these issues to facilitate better care of dying patients in the ICU.

Special nursing considerations

Caring for a critically ill patient with cancer requires another dimension of care when compared with caring for patients in a general ICU. The oncology critical care staff deals with an acute event and with the multidimensional aspects of care of a patient with a cancer diagnosis. Goals of care include a reduction in the number and severity of disease- and treatment-related adverse sequelae. Effective management requires a multidisciplinary approach to care. Skilled and knowledgeable care and communication among all members of the team are essential to prevent, minimize, and treat these symptoms and to achieve optimal patient outcomes.

A measure of critical care nurses' post-code stress

AIM

The purpose of this research was to develop an instrument to measure critical care nurses' post-code stress and then to examine the psychometric properties.

BACKGROUND

Critical care nurses experience stress from multiple sources. One source of stress may arise from participation in resuscitation attempts and this has been labelled post-code stress; however, no means exist for measuring this source of stress.

DESIGN/METHOD

In phase 1, 47 items were developed and submitted to a panel of experts for content validity. Based on content experts' ratings, 20 items were retained for phase 2 instrument testing. To test the instrument, a convenience sample of critical care nurses was obtained from four institutions in north-eastern United States. Each nurse received the Post-Code Stress Scale and completed it anonymously. A subsample completed the Post-Code Stress Scale a second time to assess stability reliability. The Nursing Stress Scale was also administered to assess construct validity.

RESULTS/FINDINGS

An exploratory principal components factor analysis with varimax rotation suggested five dimensions to post-code stress. These five dimensions accounted for 66% of the variance and indicated that stress arose from feeling discomposed, oppressed, uncertain, burdened and morally conflicted. The Pearson product moment correlation between the Post-Code Stress Scale and the Nursing Stress Scale was 0.46, providing preliminary evidence of construct validity. Internal consistency reliability estimates for the five-factor subscales ranged from 0.57 to 0.77 with only one factor being <0.70. The internal consistency reliability estimate for the final 14 items on the scale was 0.79.

CONCLUSIONS

The instrument shows promise as a measure of post-code stress based on the evidence obtained in this study; however, further psychometric testing is warranted.