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

Defining a Good Death (Successful Dying): Literature Review and a Call for Research and Public Dialogue

There is little agreement about what constitutes good death or successful dying. The authors conducted a literature search for published, English-language, peer-reviewed reports of qualitative and quantitative studies that provided a definition of a good death. Stakeholders in these articles included patients, prebereaved and bereaved family members, and healthcare providers (HCPs). Definitions found were categorized into core themes and subthemes, and the frequency of each theme was determined by stakeholder (patients, family, HCPs) perspectives. Thirty-six studies met eligibility criteria, with 50% of patient perspective articles including individuals over age 60 years. We identified 11 core themes of good death: preferences for a specific dying process, pain-free status, religiosity/spirituality, emotional well-being, life completion, treatment preferences, dignity, family, quality of life, relationship with HCP, and other. The top three themes across all stakeholder groups were preferences for dying process (94% of reports), pain-free status (81%), and emotional well-being (64%). However, some discrepancies among the respondent groups were noted in the core themes: Family perspectives included life completion (80%), quality of life (70%), dignity (70%), and presence of family (70%) more frequently than did patient perspectives regarding those items (35%-55% each). In contrast, religiosity/spirituality was reported somewhat more often in patient perspectives (65%) than in family perspectives (50%). Taking into account the limitations of the literature, further research is needed on the impact of divergent perspectives on end-of-life care. Dialogues among the stakeholders for each individual must occur to ensure a good death from the most critical viewpoint-the patient's.

ICU Bedside Nurses' Involvement in Palliative Care Communication: A Multicenter Survey

CONTEXT

Successful and sustained integration of palliative care into the intensive care unit (ICU) requires the active engagement of bedside nurses.

OBJECTIVES

To describe the perspectives of ICU bedside nurses on their involvement in palliative care communication.

METHODS

A survey was designed, based on prior work, to assess nurses' perspectives on palliative care communication, including the importance and frequency of their involvement, confidence, and barriers. The 46-item survey was distributed via e-mail in 2013 to bedside nurses working in ICUs across the five academic medical centers of the University of California, U.S.

RESULTS

The survey was sent to 1791 nurses; 598 (33%) responded. Most participants (88%) reported that their engagement in discussions of prognosis, goals of care, and palliative care was very important to the quality of patient care. A minority reported often discussing palliative care consultations with physicians (31%) or families (33%); 45% reported rarely or never participating in family meeting discussions. Participating nurses most frequently cited the following barriers to their involvement in palliative care communication: need for more training (66%), physicians not asking their perspective (60%), and the emotional toll of discussions (43%).

CONCLUSION

ICU bedside nurses see their involvement in discussions of prognosis, goals of care, and palliative care as a key element of overall quality of patient care. Based on the barriers participants identified regarding their engagement, interventions are needed to ensure that nurses have the education, opportunities, and support to actively participate in these discussions.

L’utilisation des échelles de niveaux d’interventions médicales en centre hospitalier

Different care settings in Quebec use levels of medical intervention forms, also called levels of care (LOC), to determine the code status of patients and to improve end-of-life care planning. It is not currently possible to know whether the levels of care in hospitals benefit patients and staff in facilitating the decision making process of treatment options and resuscitation measures. No study, to the best of the authors’ knowledge, has been published about LOC, particularly in Quebec and Canada. This literature review was undertaken on levels of care in order to clarify this topic. Relevant articles are discussed under different themes that are pertinent to LOC. The themes addressed in this article include care at the end of life, do-not-resuscitate orders, treatment withdrawal, and decision making at end of life.

Exploring Health Care Providers' Views About Initiating End-of-Life Care Communication

Numerous factors impede effective and timely end-of-life (EOL) care communication. These factors include delays in communication until patients are seriously ill and/or close to death. Gaps in patient-provider communication negatively affect advance care planning and limit referrals to palliative and hospice care. Confusion about the roles of various health care providers also limits communication, especially when providers do not coordinate care with other health care providers in various disciplines. Although providers receive education regarding EOL communication and care coordination, little is known about the roles of all health care providers, including nonphysician support staff working with physicians to discuss the possibility of dying and help patients prepare for death. This study explores the perspectives of physicians, nurses, social workers, and chaplains on engaging seriously ill patients and families in EOL care communication. Qualitative data were from 79 (medical and nonmedical) providers practicing at 2 medical centers in Central Los Angeles. Three themes that describe providers' perceptions of their roles and responsibility in talking with seriously ill patients emerged: (1) providers' roles for engaging in EOL discussions, (2) responsibility of physicians for initiating and leading discussions, and (3) need for team co-management patient care. Providers highlighted the importance of beginning discussions early by having physicians lead them, specifically due to their medical training and need to clarify medical information regarding patients' prognosis. Although physicians are a vital part of leading EOL communication, and are at the center of communication of medical information, an interdisciplinary approach that involves nurses, social workers, and chaplains could significantly improve patient care.

Dying Care Interventions in the Intensive Care Unit

PURPOSE

Providing high-quality end-of-life care is a challenging area in intensive care practice. The aim of the current study was to assess the practice of registered nurses (RNs) with respect to dying care and spiritual support interventions in intensive care units (ICUs) in the Czech Republic (CR) and find correlations between particular factors or conditions and the frequency of NIC interventions usage.

DESIGN AND METHODS

A cross-sectional, descriptive study was designed. A questionnaire with Likert scales included the particular activities of dying care and spiritual support interventions and an evaluation of the factors influencing the implementation of the interventions in the ICU. The group of respondents consisted of 277 RNs working in 29 ICUs in four CR regions. The Mann-Whitney U test and Pearson correlation coefficient were used for statistical evaluation.

FINDINGS

The most and least frequently reported RN activities were "treat individuals with dignity and respect" and "facilitate discussion of funeral arrangements," respectively. The frequencies of the activities in the biological, social, psychological, and spiritual dimensions were negatively correlated with the frequency of providing care to dying patients. A larger number of activities were related to longer lengths of stay in the ICU, higher staffing, more positive opinions of the RNs regarding the importance of education in a palliative care setting, and attending a palliative care education course.

CONCLUSIONS

The psychosocial and spiritual activities in the care of dying patients are used infrequently by RNs in CR ICUs. The factors limiting the implementation of palliative care interventions and strategies improving implementation warrant further study.

CLINICAL RELEVANCE

Assessment of nursing activities implemented in the care of dying patients in the ICU may help identify issues specific to nursing practice.

Engaging Patients With Advance Directives Using an Information Visualization Approach

Despite the benefits of advance directives (AD) to patients and care providers, they are often not completed due to lack of patient awareness. The purpose of the current article is to advocate for creation and use of an innovative information visualization (infovisual) as a health communication tool aimed at improving AD dissemination and engagement. The infovisual would promote AD awareness by encouraging patients to learn about their options and inspire contemplation and conversation regarding their end-of-life (EOL) journey. An infovisual may be able to communicate insights that are often communicated in words, but are much more powerfully communicated by example. Furthermore, an infovisual could facilitate vivid understanding of options and inspire the beginning of often difficult conversations among care providers, patients, and loved ones. It may also save clinicians time, as care providers may be able to spend less time explaining details of EOL care options. Use of an infovisual could assist in ensuring a well-planned EOL journey.

End-of-life care provision: experiences of intensive care nurses in Iraq

BACKGROUND

Nurses play a key role in providing care for the critically ill in the intensive care unit (ICU). The physical, psychological, emotional and spiritual intimate care given by Kurdish nurses allows them to develop a therapeutic relationship with terminally ill patients in the ICU.

AIMS

This study sought to explore the meaning of caring for terminally ill patients from the perspective of Kurdish ICU nurses.

DESIGN

Van Manen's (1990) hermeneutic phenomenological design was adopted.

METHOD

The data were collected through in-depth semi-structured interviews with a purposive sample of 10 nurses working in ICUs. Interviews were transcribed and finally analysed according to Van Manen's method.

RESULTS

Four major themes including emotional labour, death as a positive dimension, optimistic rather than futile care and working within constraints emerged.

CONCLUSIONS

Kurdish nurses in their caring encounters with terminally ill patients experienced a range of feelings from emotional strain to being optimistic while working within limited resources in the ICU. Further research is needed to explore the experiences of nurses with other cultures of caring for terminally ill patients in ICUs.

RELEVANCE TO PRACTICE

End-of-life care in ICU is emotionally challenging, therefore, nurses in this setting require psychological and spiritual support to ensure optimal care provision.

Clergy Views on a Good Versus a Poor Death: Ministry to the Terminally Ill

BACKGROUND

Clergy are often important sources of guidance for patients and family members making medical decisions at the end-of-life (EOL). Previous research revealed spiritual support by religious communities led to more aggressive care at the EOL, particularly among minority patients. Understanding this phenomenon is important to help address disparities in EOL care.

OBJECTIVE

The study objective was to explore and describe clergy perspectives regarding "good" versus "poor" death within the participant's spiritual tradition.

METHODS

This was a qualitative, descriptive study. Community clergy from various spiritual backgrounds, geographical locations within the United States, and races/ethnicities were recruited. Participants included 35 clergy who participated in one-on-one interviews (N = 14) and two focus groups (N = 21). Semistructured interviews explored clergy viewpoints on factors related to a "good death." Principles of grounded theory were used to identify a final set of themes and subthemes.

RESULTS

A good death was characterized by wholeness and certainty and emphasized being in relationship with God. Conversely, a "poor death" was characterized by separation, doubt, and isolation. Clergy identified four primary determinants of good versus poor death: dignity, preparedness, physical suffering, and community. Participants expressed appreciation for contextual factors that affect the death experience; some described a "middle death," or one that integrates both positive and negative elements. Location of death was not viewed as a significant contributing factor.

CONCLUSIONS

Understanding clergy perspectives regarding quality of death can provide important insights to help improve EOL care, particularly for patients highly engaged with faith communities. These findings can inform initiatives to foster productive relationships between clergy, clinicians, and congregants and reduce health disparities.

[Nurses' perception, experience and knowledge of palliative care in intensive care units]

BACKGROUND

Adequate provision of palliative care by nursing in intensive care units is essential to facilitate a "good death" to critically ill patients.

OBJECTIVE

To determine the perceptions, experiences and knowledge of intensive care nurses in caring for terminal patients.

METHODOLOGY

A literature review was conducted on the bases of Pubmed, Cinahl and PsicINFO data using as search terms: cuidados paliativos, UCI, percepciones, experiencias, conocimientos y enfermería and their alternatives in English (palliative care, ICU, perceptions, experiences, knowledge and nursing), and combined with AND and OR Boolean. Also, 3 journals in intensive care were reviewed.

RESULTS

Twenty seven articles for review were selected, most of them qualitative studies (n=16). After analysis of the literature it has been identified that even though nurses perceive the need to respect the dignity of the patient, to provide care aimed to comfort and to encourage the inclusion of the family in patient care, there is a lack of knowledge of the end of life care in intensive care units' nurses.

CONCLUSION

This review reveals that to achieve quality care at the end of life, is necessary to encourage the training of nurses in palliative care and foster their emotional support, to conduct an effective multidisciplinary work and the inclusion of nurses in decision making.

Supporting families of dying patients in the intensive care units

Family support in the intensive care units is a challenge for nurses who take care of dying patients. This article aimed to determine the Iranian nurses' experience of supporting families in end-of-life care. Using grounded theory methodology, 23 critical care nurses were interviewed. The theme of family support was extracted and divided into 5 categories: death with dignity; facilitate visitation; value orientation; preparing; and distress. With implementation of family support approaches, family-centered care plans will be realized in the standard framework.

Factors influencing the provision of end-of-life care in critical care settings: development and testing of a survey instrument

AIM

To develop and psychometrically test a survey instrument to identify the factors influencing the provision of end-of-life care by critical care nurses.

BACKGROUND

Following a decision to withdraw life-sustaining treatment, critical care nurses remain with the patient and their family providing end-of-life care. Identification of factors influencing the provision of this care can give evidence to inform practice development and support nurses.

DESIGN

A cross-sectional survey of critical care nurses.

METHOD

An online survey was developed, reviewed by an expert panel and pilot tested to obtain preliminary evidence of its reliability and validity. In May 2011, a convenience sample of critical care nurses (n = 392, response rate 25%) completed the survey. The analytical approach to data obtained from the 58 items measured on a Likert scale included exploratory factor analysis and descriptive statistics.

RESULTS

Exploratory factor analysis identified eight factors influencing the provision of end-of-life care: emotional support for nurses, palliative values, patient and family preferences, resources, organizational support, care planning, knowledge and preparedness. Internal consistency of each latent construct was deemed satisfactory. The results of descriptive statistics revealed a strong commitment to the inclusion of families in end-of-life care and the value of this care in the critical care setting.

CONCLUSION

This paper reports preliminary evidence of the psychometric properties of a new survey instrument. The findings may inform practice development opportunities to support critical care nurses in the provision of end-of-life care and improve the care that patients and their families receive.

Is a good death possible in Australian critical and acute settings?: physician experiences with end-of-life care

Background

In Australia approximately 70% of all deaths are institutionalised but over 15% of deaths occur in intensive care settings where the ability to provide a “good death” is particularly inhibited. Yet, there is a growing trend for death and dying to be managed in the ICU and physicians are increasingly challenged to meet the new expectations of their specialty. This study examined the unexplored interface between specialised Australian palliative and intensive care and the factors influencing a physician’s ability to manage deaths well.

Method

A qualitative investigation was focused on palliative and critical/acute settings. A thematic analysis was conducted on semi-structured in-depth interviews with 13 specialist physicians. Attention was given to eliciting meanings and experiences in Australian end-of-life care.

Results

Physicians negotiated multiple influences when managing dying patients and their families in the ICU. The way they understood and experienced end-of-life care practices was affected by cultural, institutional and professional considerations, and personal values and beliefs. Interpersonal and intrapsychic aspects highlighted the emotional and psychological relationship physicians have with patients and others. Many physicians were also unaware of what their cross-disciplinary colleagues could or could not do; poor professional recognition and collaboration, and ineffective care goal transition impaired their ability to assist good deaths. Experience was subject to the efficacy of physicians in negotiating complex bedside dynamics.

Conclusions

Regardless of specialty, all physicians identified the problematic nature of providing expert palliation in critical and acute settings. Strategies for integrating specialised palliative and intensive care were offered with corresponding directions for future research and clinical development.

Practical knowledge of experienced nurses in critical care: a qualitative study of their narratives

BACKGROUND

Scholars of nursing practices have claimed practical knowledge is source of knowledge in its own right, nevertheless we know little about this knowledge associated with day-to-day practice. The purpose of this study is to describe knowledge that the more experienced nurses the in ICU make use of and discover the components of care it includes. Understanding this knowledge can contribute to improving the working practices of nurses with less experience.

METHODS

We used a phenomenologic and hermeneutic approach to conduct a qualitative study. Open in-depth dialogue interviews were conducted with 13 experienced ICU nurses selected by intentional sampling. Data was compiled on significant stories of their practice. The data analysis enabled units of meaning to be categorised and grouped into topics regarding everyday practical knowledge.

RESULTS

Knowledge related to everyday practice was evaluated and grouped into seven topics corresponding to how the ICU nurses understand their patient care: 1) Connecting with, calming and situating patients who cannot communicate; 2) Situating and providing relief to patients in transitions of mechanical respiration and non-invasive ventilation; 3) Providing reassurance and guaranteeing the safety of immobilised patients; 4) The "connection" with patients in comas; 5) Taking care of the body; 6) The transition from saving life to palliative care; and 7) How to protect and defend the patient from errors. The components of caretaking that guarantee success include: the calm, care and affection with which they do things; the time devoted to understanding, situating and comforting patients and families; and the commitment they take on with new staff and doctors for the benefit of the patient.

CONCLUSIONS

These results show that stories of experiences describe a contextual practical knowledge that the more experienced nurses develop as a natural and spontaneous response. In critical patients the application of everyday practical knowledge greatly influences their well-being. In those cases in which the nurses describe how they have protected the patients from error, this practical knowledge can mean the difference between life and death. The study highlights the need to manage practical knowledge and undertake further research. The study is useful in keeping clinical practice up-to-date.

Preference of Chinese general public and healthcare providers for a good death

Objectives:

The aim of this study is to find and compare the current situation between common people and healthcare providers’ preferences for a good death in the context of Chinese culture.

Methods:

A cross-sectional anonymous questionnaire survey covering 190 ordinary Chinese people and 323 healthcare providers was conducted. An inventory of the good death was translated and the subjects were surveyed about their attitude toward it.

Ethical considerations:

Permission to conduct the study was granted by department chiefs, nurse managers and the participants themselves. The participants were informed that they took part on a voluntary and anonymous basis, that they could withdraw at any time, that they had the right to ignore questions they did not wish to answer, and that whatever they chose to do would not jeopardize their employment conditions.

Results:

The attributes that were perceived as important by major respondents for a good death were maintaining hope and pleasure, good relationship with medical staff, good relationship with family, independence, environment comfort, being respected as an individual, preparation for death, physical and psychological comfort, dying in a favorite place, and not being a burden to others. And some relatively less important characteristics were life completion, receiving enough treatment, natural death, controlling over the future, unawareness of death, pride and beauty, feeling that one’s life is worth living, and religious and spiritual comfort. We also found that healthcare providers were more likely than general out-patients to perceive “physical and psychological comfort,” “dying in a favorite place,” “good relationship with medical staff,” and “natural death” as important for a good death.

Conclusion:

This study offers healthcare providers in China a fundamental understanding of the normal expectations of the general public for a good death. It is believed that these findings in our study are valuable to improve palliative care in China. We compared the attitudes of Chinese and Westerners and found some differences, which suggested that cultural difference should be an important consideration to achieve a good death in China. We also found that healthcare providers see good death differently from general public, indicating that the criteria for good death warrant further study.

Determining the factors contributing to quality of life of patients at the last stage of life: a qualitative study

BACKGROUND

Quality- of- life of patients at their last stage of their life are different from that of other people.

OBJECTIVES

The aim of this study was to determine the factors contributing to the quality- of- life of patients at their last stage of their life and provide good cares for these patients.

PATIENTS AND METHODS

This qualitative study was performed by the thematic- framework method of analysis. Twenty three participants including patients, their families, nurses, physicians, psychologists and clergymen were selected sampling. Data were collected by semi - structured interview. We used the thematic framework method to analyze qualitative data.

RESULTS

Seven factors which needed to be considered in the patients' at last stage quality of life included stress reduction, participation, homecare, education, independency, support, recourses and facilities. According to the findings, the number of these factors may be more than what was mentioned above.

CONCLUSIONS

Paying attention to the quality of life at the last stage can be helpful for patients and their families and the special care can be taken for them.

Commitment to care: a qualitative study of intensive care nurses' perspectives of end-of-life care in an Islamic context

BACKGROUND

Currently, end-of-life care is a significant issue and a topic of debate in intensive care settings but understanding of nurses' perspectives about this within an Islamic context is surprisingly lacking.

AIM

The purpose of this study was to explore intensive care nurses' perspectives of the end-of-life care in South-east of Iran.

METHODS

A descriptive qualitative research approach was used to engage 12 intensive care nurses from three intensive care units of teaching hospitals affiliated to Kerman University of Medical Science in a semi-structured interview. Interview transcripts were analysed using an inductive coding approach.

RESULTS

Four major categories emerged from analysis of the interviews: commitment to care, awareness of dying patients, caring relationships, and dealing with barriers and ethical issues. The first category was emphasized and appeared dominant in all interviews.

LIMITATION

Because of specific socio-cultural and environmental factors, the findings of this study may not be applicable in other contexts, but enhance our knowledge about the topic in an Islamic context.

CONCLUSIONS

This study emphasizes the importance of looking at the end-of-life care for critical terminally ill patients within the context of spiritual milieu associated with commitment to a compassionate care until the last moment of their life. Intensive nurses, faced with various barriers and ethical issues, instead were focused on physical and spiritual care and believed that it should fulfil their role in the challenging process.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

These findings indicate that there is a need for policies that help increase the quality of life of dying patients. It is imperative that nursing managers and policy makers in Iran consider these findings to improve end-of-life care in intensive setting. More training programmes, further education and research on the topic, should be implemented.

Bedside nurse involvement in end-of-life decision making: a brief review of the literature

Bedside nurses in the critical care setting deal with death on a regular basis. Historically, end-of-life decision making has been addressed by physicians with the family and patient, yet nurses may be a better resource for families during the decision-making process. The purpose of this article was to provide a brief review of literature surrounding end-of-life decision making. As patient advocates, nurses should be more actively involved with facilitating the end-of-life decision-making process for critically ill patients and their families.

Biofield Therapies for Symptom Management in Palliative and End-of-Life Care

Terminally ill patients experience negative symptoms at end of life (EOL) that hinder well-being and quality of life (QOL). Current intervention strategies are not always effective or feasible. A focused literature review to evaluate the use of biofield therapies (ie, Therapeutic Touch, Healing Touch, and Reiki) to manage the symptoms in EOL revealed no studies on the use these therapies, specifically in this population. Evidence from studies on relevant populations (patients with cancer, elderly patients, and patients experiencing chronic pain), which addressed the outcomes relevant to palliative and EOL care (EOLC; pain levels, changes in psychological symptoms, well-being, and QOL), supports the use of biofield therapies in relieving pain, improving QOL and well-being, and reducing psychological symptoms of stress. Further research to assess the use of biofield therapies in EOLC is clearly needed.

Managing futility in critically ill patients with cardiac disease

Despite extraordinary innovations in cardiology and critical care, cardiovascular disease remains the leading cause of death globally, and heart failure has one of the highest disease burdens of any medical condition in the Western world. The lethality of many cardiac conditions, for which symptoms and prognoses are worse than for many malignancies, is widely under-recognized. A number of strategies have been developed within specialties such as oncology to improve the care of patients with life-threatening conditions. For reasons that are multifactorial, these options are often denied to critically ill patients with cardiac disease. Cardiologists and intensivists often regard death as failure, continuing to pursue active treatment while potentially denying patients access to alternatives such as symptom control and end-of-life care. Patient autonomy is central to the delivery of high-quality care, demanding shared decision-making to ensure patient preferences are acknowledged and respected. Although many cardiologists and intensivists do provide thoughtful and patient-centred care, the pressure to intervene can lead to physician-centric care focused around the needs and wishes of medical staff to the detriment of patients, families, health-care workers, and society as a whole.

The Care of the Actively Dying in an Academic Medical Center

Background:

Care of the dying is a significant component of nursing practice particularly in hospitals. Nurses who work in certain areas like oncology, intensive care unit (ICU) face the care of the dying, more so than other units.

Objectives:

The survey was conducted to assess nurses' self-perception of their professional capability and comfort in the care of the actively dying. Determine if professional capability and comfort was associated with any of the six demographics characteristics (age, gender, clinical experience, education level, nursing unit, continuing education). Identify areas of clinical challenge to promote educational initiatives to stimulate best nursing practice in the actively dying.

Design:

The survey comprised of two parts: Part I with demographic characteristics and a single open-ended question, Part II with twenty questions on the domains recommended by the NCP.

Results:

Older age and greater clinical experience were associated with greater levels of capability/comfort. Most nurses felt professionally capable and comfortable in domains such as knowledge, physical and psychosocial care but bioethics, communication, cultural, spiritual and bereavement issues challenged ≥ 40%.

Conclusions:

Nurses self-perceived professional capability and comfort levels in caring for the dying were positively influenced by older age, greater clinical experience and extensive continuing education. Bioethics, communication and grief impacted nurses personally and emotionally. Continuing education, organized debriefing, grief-counseling, and preceptors support should be routine for nurses who work in units with predictable high mortality.

"A room full of chairs around his bed": being present at the death of a loved one in Veterans Affairs Medical Centers

Historically, death took place at home where family held vigil around the dying patient. Today, family presence is an important feature of death and dying in hospital settings. We used hermeneutic phenomenology to explore experiences of being present at the hospital death of a loved one. We conducted in-depth, face-to-face interviews with 78 recently bereaved next-of-kin of veterans who died in 6 Veterans Affairs (VA) Medical Centers in the Southeast United States. Two major themes emerged: 1) "settling in," characteristic of the experiences of wives and daughters in the initial phase of the patient's hospitalization; and 2) "gathering around," characteristic of the experiences of a wider array of family members as the patient neared death. An in-depth understanding of experiences of next-of-kin present at the hospital death of a loved one can increase staff awareness of family's needs and empower staff to develop policies and procedures for supporting family members.

Efficacy of the End-of-Life Nursing Care Continuing Education Program for Nurses in General Wards in Japan

This study aimed to examine effectiveness of the End-of-life nursing care continuing education program for general ward nurses. A nonrandomized, before-after trial was conducted. The program was implemented for 25 nurses. The contents of the program consisted of the family assessment, general symptom management and practical use of theories and models regarding end-of-life nursing care. The primary outcome, implementation ability of end-of-life nursing care, was significantly improved after the program; improvements continued even at 2 months after. Similar results were obtained for nurses' confidence and knowledge concerning end-of-life nursing care. As for attitude toward end-of-life care, participants' scores were further elevated after the program. The participants rated the usefulness of the program as high. The effectiveness of the program was suggested from these results. In the future, this program should be widely used for in-service training.

Reactions to patient death: the lived experience of critical care nurses

A qualitative study using phenomenological descriptive design was conducted to explore critical care nurses' experiences with patient death. Several themes emerged as a result of this study: coping, personal distress, emotional disconnect, and inevitable death. Understanding critical care nurses' reactions to patient death may help to improve the care provided to critically ill dying patients and their families and to meet the needs of the nurses who care for them.

Prognostic communication of critical care nurses and physicians at end of life

Many critical care nurses express reluctance to communicate prognostic information to patients and family members, especially prior to physician communication of this information. Yet, the findings from this study indicate that critical care nurses play a crucial, complementary role to physicians in prognostic communication. Nurses' contributions result in a broader picture of prognosis to patients and family members and facilitate end-of-life discussions.

Factors and Structural Model Related to End-of-Life Nursing Care in General Ward in Japan

This study aimed to determine the factors related to the implementation of end-of-life nursing care in general wards and to examine the adequacy of the hypothetical care implementation model. A cross-sectional survey was conducted. As the results of multiple regression analysis, 8 factors were determined: subjective evaluation of nurses’ own team, positive attitudes toward caring for dying persons, existence of a role model, death relief (Death Attitude Inventory), knowledge of symptom management knowledge of family assessment, abstract judgment skill, and participation in the seminar. The hypothetical model was constructed using these factors, and the adequacy of this model was confirmed by a structural equation modeling. These factors and the model would give suggestions of educational content and its method, which should be provided to general ward nurses.

Providing a "good death" for oncology patients during the final hours of life in the intensive care unit

Cancer is a leading cause of death in the United States. Aggressiveness of cancer care continues to rise in parallel with scientific discoveries in the treatment of a variety of malignancies. As a result, patients with cancer often require care in intensive care units (ICUs). Although growth in hospice and palliative care programs has occurred nationwide, access to these programs varies by geographic region and hospital type. Thus, critical care nurses may be caring for patients with cancer during the final hours of life in the ICU without the support of palliative care experts. This article provides an overview of the meaning of the final hours of life for cancer patients and uses principles of a "good death" and the tenets of hospice care to organize recommendations for critical care nurses for providing high quality end-of-life care to patients with cancer in the ICU.

Thai Buddhist families' perspective of a peaceful death in ICUs

AIM

To describe the concept of a peaceful death in intensive care units (ICUs) from the perspective of Thai Buddhist family members.

METHODS

This descriptive qualitative study was based on data generated from individual in-depth interviews of nine Thai Buddhist family members from the southern region of Thailand whose loved ones died in adult ICUs. Colaizzi's phenomenological approach was used to analyse the data. Rigour for the study was established by Lincoln and Guga's guidelines for qualitative research studies.

FINDINGS

Five core qualities emerged that made-up the concept of a peaceful death as described by Thai Buddhist family members who cared for their loved ones while they were dying in ICUs. These core qualities were 'knowing death was impending, preparing for a peaceful state of mind, not suffering, being with family members and not alone, and family members were not mourning'.

CONCLUSION

Thai Buddhist family members described what they meant by a peaceful death. 'This was: preparing for a peaceful state of mind in knowing that one's impending death is not a situation of suffering or being alone, but rather a time of being with family members who are not yet mourning one's death.' The findings support that family members should participate in promoting a peaceful death for their loved ones dying in ICUs.

IMPLICATIONS FOR PRACTICE

The five core qualities of a peaceful death reported in this study could be used as a framework for nurses to create nursing practice interventions for quality end-of-life care for Thai Buddhists.

Thai Nurses’ Experience of Caring for Persons Who Had a Peaceful Death in Intensive Care Units

This phenomenological study describes the lived experience of caring for persons who had a peaceful death in the intensive care units. Ten intensive care nurses in south Thailand participated in individual interviews. Van Manen’s approach was utilized to synthesize data. The lived experience of Thai nurses caring for persons who had a peaceful death is: understanding the other through valuing experience and enhancing relationships with others by recognizing time is short and is a priority. Boykin and Schoenhofer’s theory of nursing as caring provided the theoretical lens for interpreting the meaning of the phenomenon.

The Going Home Initiative: Getting Critical Care Patients Home With Hospice

Although considerable effort is being directed at providing patients and their families with a “good death,” most patients in intensive care units, if given the choice, would prefer to die at home. With little guidance from the literature, the palliative care committee of an intensive care unit developed guidelines to get patients home from the intensive care unit to die. In the past few years, the unit has transferred many patients home with hospice care, much to the delight of their families. Although several obstacles to achieving this goal exist, the unit has achieved success in a small-scale implementation of its Going Home Initiative.

Nursing the patient with complex communication needs: time as a barrier and a facilitator to successful communication in hospital

BACKGROUND

Effective nurse-patient communication is an essential aspect of health care. Time to communicate, however, is limited and subject to workload demands. Little is known about how nurses manage this 'lack of time' when caring for patients with developmental disability and complex communication needs, who typically communicate at a slow rate.

AIM

The aim of this study was to investigate nurses' expressed concepts of 'time' in stories about communicating with patients with developmental disability and complex communication needs in hospital.

METHOD

In 2009, 15 hospital nurses from a range of wards in two metropolitan hospitals participated in interviews about barriers to and strategies for successful communication with patients with developmental disability and complex communication needs in hospital. The data were analysed using narrative inquiry methodology and the stories verified with the participants.

RESULTS

Nurses identified 'time' as a barrier and a facilitator to successful communication. Time as a barrier was related thematically to avoiding direct communication and preferring that family or paid carers communicated on behalf of the patient. Time as a facilitator was related to valuing communication, investing extra time, and to applying a range of adaptive communication strategies to establish successful communication.

CONCLUSIONS

Time is perceived by nurses as both an enemy and friend for improving communication. Nurses who perceive that communication takes too long may avoid communication and miss opportunities to improve communication through increased familiarity with the person's communication methods. Those who take time to communicate narrate applying a range of strategies to achieve success in basic needs communication.

Knowing the occasion of a peaceful death in intensive care units in Thailand

The purpose of this study was to describe how nurses know the occasion of a peaceful death. The data were generated from individual in-depth interviews with ten nurses who practised in adult intensive care units in the southern region of Thailand. Using a content analysis method, four processes of knowing the occasion of a peaceful death were isolated. They were visual knowing, technological knowing, intuitive knowing, and relational knowing.The clinical implications of these processes provide opportunities for nurses to practise the best end-of-life care during a critical time in a patient's life.This study also strengthens cross-cultural nursing during end-of-life care in high-technology settings, such as the intensive care unit.

Conducting a large survey of critical care nurses in Canada: lessons learnt

INTRODUCTION

Survey research provides information regarding clinician opinion, adherence to evidence-based recommendations and practice variation. Yet, the conduct of large surveys can present numerous challenges. Practical challenges such as establishing a sampling strategy consistent with a population's distribution may be anticipated. Additional unanticipated challenges may emerge during survey implementation that require troubleshooting and result in additional costs.

OBJECTIVE

Our objective is to inform nurse clinicians and researchers of our experiences in the conduct of a large, Canadian survey of critical care nurses. Specifically, we describe administrative, financial and logistical considerations and challenges.

RESULTS

Administrative challenges included negotiation with each provincial/territorial nursing association to facilitate survey distribution. Financial considerations included anticipated and unanticipated costs such as postage, nursing association fees, translation, printing, shipping and research assistant time. Logistical challenges included systematizing survey mail outs and tracking, and translating survey materials and responses for bilingual provinces.

CONCLUSION

Conduct of this large national survey required considerable financial resources, time, energy and coordination. We anticipate greater understanding of the work and cost associated with planning and implementing such surveys may inform researchers as well as critical care nurses considering responding to future survey invitations.

EvaIuating the "good death" concept from Iranian bereaved family members' perspective

Improving end-of-life care demands that first you define what constitutes a good death for different cultures. This study was conducted to evaluate a good death concept from the Iranian bereaved family members' perspective. A descriptive, cross-sectional study was designed using a Good Death Inventory (GDI) questionnaire to evaluate 150 bereaved family members. Data were analyzed by SPSS. Based on the results, the highest scores belonged to the domains "being respected as an individual," "natural death," "religious and spiritual comfort," and "control over the future." The domain perceived by family members as less important was "unawareness of death." Providing a good death requires professional caregivers to be sensitive and pay attention to the preferences of each unique person's perceptions. In order to implement holistic care, caregivers must be aware of patients' spiritual needs. Establishing a specific unit in a hospital and individually treating each patient as a valued family member could be the best way to improve the quality of end-of-life care that is missing in Iran.

Pediatric nurses' individual and group assessments of palliative, end-of-life, and bereavement care

BACKGROUND

Although pediatric nurses working in children's hospitals often provide care to dying children, little is known about their palliative care beliefs and experiences as individuals or members of groups within the hospital.

OBJECTIVE

To describe pediatric nurses' ratings of palliative care goals and problems, as individuals and members of clusters of nurses with similar views, and nurses' degree of collaboration with an inpatient palliative care team across hospital units.

METHOD

A cross-sectional survey of nurses at a freestanding children's hospital in 2005.

RESULTS

Nurses rated the most important goals as managing pain, maintaining the child's quality of life, and improving communication. Commonly cited problems were lack of opportunity to debrief after a patient's death, uncertainty about the goals of care, and the health care team's reluctance to discuss hospice with family. Based on individual views about goals and problems, nurses clustered into 5 groups that differed in terms of the adamancy of their views and the scope of the goals and problems they considered important or significant. The hospital unit was the most important factor in predicting nurses' degree of collaboration with the palliative care team even after accounting for individual characteristics.

CONCLUSIONS

Pediatric nurses broadly endorse both the importance of palliative care goals and the presence of problems yet perceive the importance of these goals and problems differently. Further, they vary in their level of collaborative practice with a palliative care team in ways that should be accounted for when planning and implementing palliative care programs.