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Willemse S, Smeets W, van Leeuwen E, Janssen L, Foudraine N. Spiritual Care in the ICU: Perspectives of Dutch Intensivists, ICU Nurses, and Spiritual Caregivers. JOURNAL OF RELIGION AND HEALTH 2018; 57:583-595. [PMID: 28801715 PMCID: PMC5854753 DOI: 10.1007/s10943-017-0457-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Since there are no scientific data available about the role of spiritual care (SC) in Dutch ICUs, the goal of this quantitative study was twofold: first, to map the role of SC as a part of daily adult ICU care in The Netherlands from the perspective of intensivists, ICU nurses, and spiritual caregivers and second, to identify similarities and differences among these three perspectives. This study is the quantitative part of a mixed methods approach. To conduct empirical quantitative cohort research, separate digital questionnaires were sent to three different participant groups in Dutch ICUs, namely intensivists, ICU nurses, and spiritual caregivers working in academic and general hospitals and one specialist oncology hospital. Overall, 487 participants of 85 hospitals (99 intensivists, 290 ICU nurses, and 98 spiritual caregivers) responded. The majority of all respondents (>70%) considered the positive effects of SC provision to patients and relatives: contribution to mental well-being, processing and channeling of emotions, and increased patient and family satisfaction. The three disciplines diverged in their perceptions of how SC is currently evolving in terms of information, assessment, and provision. Nationwide, SC is not implemented in daily ICU care. The majority of respondents, however, attached great importance to interdisciplinary collaboration. In their view SC contributes positively to the well-being of patients and relatives in the ICU. Further qualitative research into how patients and relatives experience SC in the ICU is required in order to implement and standardize SC as a scientifically based integral part of daily ICU care.
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Affiliation(s)
- Suzan Willemse
- Spiritual Care Department, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, The Netherlands
| | - Wim Smeets
- Department of Spiritual and Pastoral Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, EZ 6525 Nijmegen, The Netherlands
| | - Evert van Leeuwen
- Department of Ethics, Philosophy and History of Medicine, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, EZ 6525 Nijmegen, The Netherlands
| | - Loes Janssen
- Department of Clinical Epidemiology, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, The Netherlands
| | - Norbert Foudraine
- Department of Critical Care, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, The Netherlands
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Richards CA, Starks H, O’Connor MR, Bourget E, Hays RM, Doorenbos AZ. Physicians Perceptions of Shared Decision-Making in Neonatal and Pediatric Critical Care. Am J Hosp Palliat Care 2018; 35:669-676. [PMID: 28990396 PMCID: PMC5673589 DOI: 10.1177/1049909117734843] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Most children die in neonatal and pediatric intensive care units after decisions are made to withhold or withdraw life-sustaining treatments. These decisions can be challenging when there are different views about the child's best interest and when there is a lack of clarity about how best to also consider the interests of the family. OBJECTIVE To understand how neonatal and pediatric critical care physicians balance and integrate the interests of the child and family in decisions about life-sustaining treatments. METHODS Semistructured interviews were conducted with 22 physicians from neonatal, pediatric, and cardiothoracic intensive care units in a single quaternary care pediatric hospital. Transcribed interviews were analyzed using content and thematic analysis. RESULTS We identified 3 main themes: (1) beliefs about child and family interests; (2) disagreement about the child's best interest; and (3) decision-making strategies, including limiting options, being directive, staying neutral, and allowing parents to come to their own conclusions. Physicians described challenges to implementing shared decision-making including unequal power and authority, clinical uncertainty, and complexity of balancing child and family interests. They acknowledged determining the level of engagement in shared decision-making with parents (vs routine engagement) based on their perceptions of the best interests of the child and parent. CONCLUSIONS Due to power imbalances, families' values and preferences may not be integrated in decisions or families may be excluded from discussions about goals of care. We suggest that a systematic approach to identify parental preferences and needs for decisional roles and information may reduce variability in parental involvement.
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Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Helene Starks
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - M. Rebecca O’Connor
- Department of Family and Child Nursing, School of Nursing, University of Washington, Seattle, WA, USA
| | - Erica Bourget
- Department of Immunology, Fred Hutchinson’s Cancer Research Center, Seattle, WA, USA
| | - Ross M. Hays
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Rehabilitative Medicine, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
- Palliative Care Program, Seattle Children’s Hospital, Seattle, WA, USA
- The Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA
| | - Ardith Z. Doorenbos
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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103
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Bannon L, McGaughey J, Clarke M, McAuley DF, Blackwood B. Designing a nurse-delivered delirium bundle: What intensive care unit staff, survivors, and their families think? Aust Crit Care 2018; 31:174-179. [PMID: 29580965 DOI: 10.1016/j.aucc.2018.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/31/2018] [Accepted: 02/04/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Implementation of quality improvement interventions can be enhanced by exploring the perspectives of those who will deliver and receive them. We designed a non-pharmacological bundle for delirium management for a feasibility trial, and we sought to obtain the views of intensive care unit (ICU) staff, survivors, and families on the barriers and facilitators to its implementation. OBJECTIVE The objective of this study is to determine the barriers and facilitators to a multicomponent bundle for delirium management in critically ill patients comprising (1) education and family participation, (2) sedation minimisation and pain, agitation, and delirium protocol, (3) early mobilisation, and (4) environmental interventions for sleep, orientation, communication, and cognitive stimulation. METHODS Nine focus group interviews were conducted with ICU staff (n = 68) in 12 UK ICUs. Three focus group interviews were conducted with ICU survivors (n = 12) and their family members (n = 2). Interviews were digitally recorded, transcribed, and thematically analysed using the Braun and Clarke framework. RESULTS Overall, staff, survivors, and their families agreed the bundle was acceptable. Facilitating factors for delivering the bundle were staff and relatives' education about potential benefits and encouraging family presence. Facilitating factors for sedation minimisation were evening ward rounds, using non-verbal pain scores, and targeting sedation scores. Barriers identified by staff were inadequate resources, poor education, relatives' anxiety, safety concerns, and ICU culture. Concerns were raised about patient confidentiality when displaying orientation materials and managing resources for early mobility. Survivors cited that flexible visiting and re-establishing normality were important factors; and staff workload, lack of awareness, and poor communication were factors that needed to be considered before implementation. CONCLUSION Generally, the bundle was deemed acceptable and deliverable. However, like any complex intervention, component adaptations will be required depending on resources available to the ICU; in particular, involvement of pharmacists in the ward round and physiotherapists in mobilising intubated patients.
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Affiliation(s)
- Leona Bannon
- School of Medicine, Dentistry & Biomedical Sciences, Queen's University Belfast, Northern Ireland, UK.
| | - Jennifer McGaughey
- School of Nursing & Midwifery, Queen's University Belfast, Northern Ireland, UK
| | - Mike Clarke
- School of Medicine, Dentistry & Biomedical Sciences, Queen's University Belfast, Northern Ireland, UK
| | - Daniel F McAuley
- School of Medicine, Dentistry & Biomedical Sciences, Queen's University Belfast, Northern Ireland, UK; Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry & Biomedical Sciences, Queen's University Belfast, Northern Ireland, UK
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104
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Addressing spirituality during critical illness: A review of current literature. J Crit Care 2018; 45:76-81. [PMID: 29413727 DOI: 10.1016/j.jcrc.2018.01.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/14/2018] [Accepted: 01/17/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The purpose of this review is to provide an overview of research on spirituality and religiosity in the intensive care setting that has been published since the 2004-2005 American College of Critical Care Medicine (ACCM) Clinical Practice Guidelines for the Support of Family in the Patient-Centered Intensive Care Unit with an emphasis on its application beyond palliative and end-of-life care. MATERIALS AND METHODS ACCM 2004-2005 guidelines emphasized the importance of spiritual and religious support in the form of four specific recommendations: [1] assessment and incorporation of spiritual needs in ICU care plan; [2] spiritual care training for doctors and nurses; [3] physician review of interdisciplinary spiritual need assessments; and [4] honoring the requests of patients to pray with them. We reviewed 26 studies published from 2006 to 2016 and identified whether studies strengthened the grade of these recommendations. We further categorized findings of these studies to understand the roles of spirituality and religiosity in surrogate perceptions and decision-making and patient and family experience. CONCLUSIONS Spiritual care has an essential role in the treatment of critically ill patients and families. Current literature offers few insights to support clinicians in navigating this often-challenging aspect of patient care and more research is needed.
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105
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Post-intensive care syndrome symptoms and health-related quality of life in family decision-makers of critically ill patients. Palliat Support Care 2017; 16:719-724. [DOI: 10.1017/s1478951517001043] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveFamily members of critically ill patients can suffer symptoms of post-intensive care syndrome-family (PICS-F), including anxiety, depression, and posttraumatic stress disorder (PTSD) with a diminished quality of life. Our aim was to examine the relationship between coping strategies used by family decision-makers (FDMs) of critically ill patients and the severity of PICS-F symptoms and to examine the relationship between FDM PICS-F symptoms and health-related quality of life (HRQOL).MethodA single-center, prospective, longitudinal descriptive study was undertaken of FDMs of intensive care unit (ICU) patients admitted to a large tertiary care hospital. PICS-F symptoms and coping strategy use were measured upon ICU admission (T1), 30 days (T2) after ICU admission, and 60 days (T3) after ICU admission. HRQOL was measured by the Short Form-36 version 2 at T1 and T3.ResultsWe found a significant prevalence of anxiety (45.8%), depression (25%), and PTSD (11.1%) symptoms among FDMs over the course of the study. The patient mortality rate in our sample was 50%. The HRQOL mental summary score in FDMs was low at T1 and decreased to M = 41.72 (standard deviation = 12.47) by T3. Avoidant coping demonstrated moderate relationships with PTSD symptoms and anxiety at T3. A previous history of anxiety, depression, or PTSD was a significant predictor of PICS-F symptom severity and prevalence. PICS symptom severity at T3 explained 75% of the variance in HRQOL mental summary score.Significance of resultsThis study describes a significant prevalence of PICS-F symptoms in FDMs with a diminished mental HRQOL.
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106
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Kon AA, Davidson JE, Morrison W, Danis M, White DB. Shared Decision-Making in Intensive Care Units. Executive Summary of the American College of Critical Care Medicine and American Thoracic Society Policy Statement. Am J Respir Crit Care Med 2017; 193:1334-6. [PMID: 27097019 DOI: 10.1164/rccm.201602-0269ed] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Alexander A Kon
- 1 Naval Medical Center San Diego San Diego, California.,2 University of California San Diego San Diego, California
| | - Judy E Davidson
- 3 University of California Health System San Diego, California
| | - Wynne Morrison
- 4 Children's Hospital of Philadelphia Philadelphia, Pennsylvania
| | - Marion Danis
- 5 National Institutes of Health Bethesda, Maryland and
| | - Douglas B White
- 6 University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
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Schoeman T, Sundararajan K, Micik S, Sarada P, Edwards S, Poole A, Chapman M. The impact on new-onset stress and PTSD in relatives of critically ill patients explored by diaries study (The "INSPIRED" study). Aust Crit Care 2017; 31:382-389. [PMID: 29254812 DOI: 10.1016/j.aucc.2017.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/03/2017] [Accepted: 11/04/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND There is rising prevalence of post-traumatic-stress-disorder (PTSD) in patients and their relatives after ICU discharge. The impact of ICU diaries on PTSD in relatives of critically ill patients in Australia has not been fully evaluated. OBJECTIVES To determine if relatives of an Australian critically ill population were interested in using ICU diaries. To determine the prevalence and impact of ICU diaries upon symptoms of PTSD, depression and anxiety in relatives of an Australian critically ill population. METHODS DESIGN Prospective, observational, exploratory study. SETTING Royal Adelaide Hospital (RAH), Adelaide, Australia. PARTICIPANTS One hundred and eight consecutive patients, staying >48h in a level 3 ICU were identified. A survey using DASS-21, IES-R questionnaires was performed on admission followed by a repeat survey 90days post discharge from ICU. An IES-R score >33 was used to define severe PTSD symptoms. A comparison between subjects who did and did not complete their diaries was performed. RESULTS Forty subjects refused to participate, eight were excluded, and sixty family members were included for analysis, thirty-six of whom completed diaries. There was no statistically significant difference between PTSD symptom scores at follow-up controlling for useful diary completion (complete - see methods) and PTSD at baseline. There was a statistically significant association between PTSD and unemployment, controlling for PTSD at baseline (P value=0.0045). Family members had significantly higher odds of PTSD at baseline compared to 3 month follow up (P value=0.0092, Odds Ratio=3.3, 95% CI: 1.3, 8.2). This was independent of the completeness of the diaries and adjusted for clustering on subject. Family members with incomplete diaries were less likely to report depressive symptoms at baseline (P value=0.0218, estimate=-4.6, 95% CI: -8.5, -0.7). Diary completion was not indicative of the likelihood of family members to report PTSD symptoms (P value=0.5468, estimate=-1.6, 95% CI: -6.8, 3.6). CONCLUSION ICU diaries were often not completed and completion did not appear to be related to the incidence of stress, anxiety, depression and PTSD symptoms in the families of patients in the ICU. This may be because Australian families are generally not interested in maintaining a diary.
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Affiliation(s)
- Tom Schoeman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.
| | - Krishnaswamy Sundararajan
- Intensive Care Unit, Royal Adelaide Hospital and the Discipline of Acute Care Medicine, University of Adelaide, Australia
| | - Svatka Micik
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Pooja Sarada
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Suzanne Edwards
- Data, Design and Statistics Service, Adelaide Health Technology Assessment (AHTA), School of Public Health, University of Adelaide, Australia
| | - Alexis Poole
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Marianne Chapman
- Intensive Care Unit, Royal Adelaide Hospital and the Discipline of Acute Care Medicine, University of Adelaide, Australia
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108
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Banyasz A, Weiskittle R, Lorenz A, Goodman L, Wells-Di Gregorio S. Bereavement Service Preferences of Surviving Family Members: Variation among Next of Kin with Depression and Complicated Grief. J Palliat Med 2017; 20:1091-1097. [DOI: 10.1089/jpm.2016.0235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alissa Banyasz
- Department of Psychiatry, Psychosocial Oncology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | | | - Amanda Lorenz
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lauren Goodman
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sharla Wells-Di Gregorio
- Department of Psychiatry, Psychosocial Oncology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
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109
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Courtright KR, Benoit DD, Halpern SD. Life after death in the ICU: detecting family-centered outcomes remains difficult. Intensive Care Med 2017; 43:1529-1531. [PMID: 28936617 DOI: 10.1007/s00134-017-4898-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 07/20/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Katherine R Courtright
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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110
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Fitchett G. Recent Progress in Chaplaincy-Related Research. THE JOURNAL OF PASTORAL CARE & COUNSELING : JPCC 2017; 71:163-175. [PMID: 28893170 DOI: 10.1177/1542305017724811] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
In light of the continued growth of chaplaincy-related research this paper presents an overview of important findings. The review summarizes research in six broad areas: what chaplains do; the importance of religion and spiritual care to patients and families; the impact of chaplains' spiritual care on the patient experience; the impact of chaplain care on other patient outcomes; spiritual needs and chaplain care in palliative and end of life care; and chaplain care for staff colleagues. It concludes with a description of several innovative and important new studies of chaplain care and notes areas for future investigation.
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Affiliation(s)
- George Fitchett
- Department of Religion, Health and Human Values, Rush University Medical Center, Chicago, IL, USA
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111
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Petrinec A. Post-Intensive Care Syndrome in Family Decision Makers of Long-term Acute Care Hospital Patients. Am J Crit Care 2017; 26:416-422. [PMID: 28864439 DOI: 10.4037/ajcc2017414] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Family members of critically ill patients experience indications of post-intensive care syndrome, including anxiety, depression, and posttraumatic stress disorder. Despite increased use of long-term acute care hospitals for critically ill patients, little is known about the impact of long-term hospitalization on patients' family members. OBJECTIVES To examine indications of post-intensive care syndrome, coping strategies, and health-related quality of life among family decision makers during and after patients' long-term hospitalization. METHODS A single-center, prospective, longitudinal descriptive study was undertaken of family decision makers of adult patients admitted to long-term acute care hospitals. Indications of post-intensive care syndrome and coping strategies were measured on the day of hospital admission and 30 and 60 days later. Health-related quality of life was measured by using the Short Form-36, version 2, at admission and 60 days later. RESULTS The sample consisted of 30 family decision makers. On admission, 27% reported moderate to severe anxiety, and 20% reported moderate to severe depression. Among the decision makers, 10% met criteria for a provisional diagnosis of posttraumatic stress disorder. At admission, the mean physical summary score for quality of life was 47.8 (SD, 9.91) and the mean mental summary score was 48.00 (SD, 10.28). No significant changes occurred during the study period. Problem-focused coping was the most frequently used coping strategy at all time points. CONCLUSION Family decision makers of patients in long-term acute care hospitals have a significant prevalence of indications of post-intensive care syndrome.
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Affiliation(s)
- Amy Petrinec
- Amy Petrinec is an assistant professor in the College of Nursing, Kent State University, Kent, Ohio
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112
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Abstract
The Neuro-ICU is a multidisciplinary location that presents peculiar challenges and opportunities for patients with life-threatening neurological disease. Communication skills are essential in supporting caregivers and other embedded providers (e.g., neurosurgeons, advanced practice providers, nurses, pharmacists), through leadership. Limitations to prognostication complicate how decisions are made on behalf of non-communicative patients. Cognitive dysfunction and durable reductions in health-related quality of life are difficult to predict, and the diagnosis of brain death may be challenging and confounded by medications and comorbidities. The Neuro-ICU team, as well as utilization of additional consultants, can be structured to optimize care. Future research should explore how to further improve the composition, communication and interactions of the Neuro-ICU team to maximize outcomes, minimize caregiver burden, and promote collegiality.
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113
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Latour JM, Coombs M. Family-centred care in Intensive Care: Moving the evidence forward-A call for papers. Intensive Crit Care Nurs 2017; 42:1-2. [PMID: 28789865 DOI: 10.1016/j.iccn.2017.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jos M Latour
- School of Nursing and Midwifery, Faculty of Health and Human Sciences, University of Plymouth, 3 Portland Villas, Room 101, Drake Circus, Plymouth PL4 8AA, United Kingdom.
| | - Maureen Coombs
- Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington, Level 7 Clinical Services Block, Wellington Regional Hospital, Riddiford Street, Newtown, Wellington 6021, New Zealand.
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114
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Liu TW, Wen FH, Wang CH, Hong RL, Chow JM, Chen JS, Chiu CF, Tang ST. Terminally Ill Taiwanese Cancer Patients' and Family Caregivers' Agreement on Patterns of Life-Sustaining Treatment Preferences Is Poor to Fair and Declines Over a Decade: Results From Two Independent Cross-Sectional Studies. J Pain Symptom Manage 2017; 54:35-45.e4. [PMID: 28450219 DOI: 10.1016/j.jpainsymman.2017.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/16/2017] [Accepted: 02/20/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT/OBJECTIVE Temporal changes have not been examined in patient-caregiver agreement on life-sustaining treatment (LST) preferences at end of life (EOL). We explored the extent of and changes in patient-caregiver agreement on LST-preference patterns for two independent cohorts of Taiwanese cancer patient-family caregiver dyads recruited a decade apart. METHODS We surveyed preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis among 1049 and 1901 dyads in 2003-2004 and 2011-2012, respectively. LST-preference patterns were examined by multi-group latent class analysis. Extent of patient-caregiver agreement on LST-preference patterns was determined by percentage agreement and kappa coefficients. RESULTS For both patients and family caregivers, we identified seven distinct LST-preference classes. Patient-caregiver agreement on LST-preference patterns was poor to fair across both study cohorts, indicated by 24.4%-43.5% agreement and kappa values of 0.06 (95% CI: 0.04, 0.09) to 0.27 (0.23, 0.30), and declined significantly over time. Agreement on LST-preference patterns was most likely when both patients and caregivers uniformly rejected LSTs. When patients disagreed with caregivers on LST-preference patterns, discrepancies were most likely when patients totally rejected LSTs but caregivers uniformly preferred LSTs or preferred nutritional support but rejected other treatments. CONCLUSION Patients and family caregivers had poor-to-fair agreement on LST-preference patterns, and agreement declined significantly over a decade. Encouraging an open dialogue between patients and their family caregivers about desired EOL care would facilitate patient-caregiver agreement on LST-preference patterns, thus honoring terminally ill cancer patients' wishes when they cannot make EOL-care decisions.
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Affiliation(s)
- Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Taiwan
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Cheng-Hsu Wang
- Division of Hematology-Oncology and Director of Cancer Center, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Ruey-Long Hong
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jyh-Ming Chow
- Section of Hematology and Medical Oncology, Wan-Fang Hospital, Taipei, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Chang-Fang Chiu
- Division of Hematology-Oncology and Comprehensive Cancer Center, China Medical University Hospital, Taichung, Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan.
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115
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Abstract
Survival of critically unwell patients has improved in the last decade due to advances in critical care medicine. Some of these survivors develop cognitive, psychiatric and /or physical disability after treatment in intensive care unit (ICU), which is now recognized as post intensive care syndrome (PICS). Given the limited awareness about PICS in the medical faculty this aspect is often overlooked which may lead to reduced quality of life and cause a lot of suffering of these patients and their families. Efforts should be directed towards preventing PICS by minimizing sedation and early mobilization during ICU.All critical care survivors should be evaluated for PICS and those having signs and symptoms of it should be managed by a multidisciplinary team which includes critical care physician, neuro-psychiatrist, physiotherapist and respiratory therapist, with the use of pharmacological and non-apharmacological interventions. This can be achieved through an organizational change and improvement, knowing the high rate of incidence of PICS and its adverse effects on the survivor's life and daily activities and its effect on the survivor's family.
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Affiliation(s)
- Gautam Rawal
- Attending Consultant, Respiratory Intensive Care, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Sankalp Yadav
- General Duty Medical Officer-II, Department of Medicine & TB, Chest Clinic Moti Nagar, North Delhi Municipal Corporation, New Delhi, India
| | - Raj Kumar
- Senior Consultant and Incharge, Respiratory Intensive Care, Max Super Specialty Hospital, Saket, New Delhi, India
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116
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Abrahamian H, Lebherz-Eichinger D. The role of psychosomatic medicine in intensive care units. Wien Med Wochenschr 2017; 168:67-75. [PMID: 28616666 DOI: 10.1007/s10354-017-0575-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 05/19/2017] [Indexed: 12/16/2022]
Abstract
Critically ill patients, their relatives, and intensive care staff are consistently exposed to stress. The principal elements of this exceptional burden are confrontation with a life-threatening disease, specific environmental conditions at the intensive care unit, and the social characteristics of intensive care medicine. The short- and long-term consequences of these stressors include a feeling of helplessness, distress, anxiety, depression, and even posttraumatic stress disorders. Not only the patients, but also their relatives and intensive care staff are at risk of developing such psychopathologies. The integration of psychosomatic medicine into the general concept of intensive care medicine is an essential step for the early identification of fear and anxiety and for understanding biopsychosocial coherence in critically ill patients. Preventive measures such as the improvement of individual coping strategies and enhancing the individual's resistance to stress are crucial aspects of improving wellbeing, as well as the overall outcome of disease. Additional stress-reducing measures reported in the published literature, such as hearing music, the use of earplugs and eye-masks, or basal stimulation, have been successful to a greater or lesser extent.
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Affiliation(s)
- Heidemarie Abrahamian
- Department of Internal Medicine, Otto Wagner Hospital, Baumgartner Höhe 1, 1140, Vienna, Austria.
| | - Diana Lebherz-Eichinger
- Department of Internal Medicine, Otto Wagner Hospital, Baumgartner Höhe 1, 1140, Vienna, Austria
- Department of Anesthesia, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Relatives' perception of stressors and psychological outcomes – Results from a survey study. J Crit Care 2017; 39:172-177. [DOI: 10.1016/j.jcrc.2017.02.036] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/18/2017] [Accepted: 02/24/2017] [Indexed: 11/20/2022]
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Association Between Resilience and Family Member Psychologic Symptoms in Critical Illness. Crit Care Med 2017; 44:e721-7. [PMID: 27097294 DOI: 10.1097/ccm.0000000000001673] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There are increased rates of depression, anxiety, and stress disorders in families of critically ill patients. Interventions directed at family members may help their ability to cope with this stress. Specifically, resilience is a teachable psychologic construct describing a person's ability to adapt to traumatic situations. Resilience can inherently assist individuals to diminish adverse psychologic outcomes. Consequently, we determined the relationship between resilience and symptoms of depression, anxiety, and acute stress in family members of critically ill patients. DESIGN This is a cross-sectional study. SETTING Three medical ICUs were screened by study staff. PATIENTS Family members of ICU patients admitted for greater than 48 hours were approached for enrollment. INTERVENTIONS The Connor-Davidson Resilience Scale was used to stratify family members as resilient or nonresilient. MEASUREMENTS AND MAIN RESULTS The Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised, and Family Satisfaction in the ICU were collected prior to ICU discharge to measure symptoms of depression, anxiety, and acute stress, as well as satisfaction with care. One-hundred and seventy family members were enrolled. Seventy-eight family members were resilient. Resilient family members had fewer symptoms of anxiety (14.2% vs 43.6%; p < 0.001), depression (14.1% vs 44.9%; p < 0.001), and acute stress (12.7% vs 36.3%; p = 0.001). Resilient family members were more satisfied with care in the ICU (76.7 vs 70.8; p = 0.008). Resilience remained independently associated with these outcomes after adjusting for family member age and gender, as well as the patient's need for mechanical ventilation. CONCLUSIONS When caring for the critically ill, resilient family members have fewer symptoms of depression, anxiety, and acute stress. Resilient families were generally better satisfied with the care delivered. These data suggest that interventions aimed at increasing resilience may improve a family member's experience in the ICU.
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Choi J, Donahoe MP, Hoffman LA. Psychological and Physical Health in Family Caregivers of Intensive Care Unit Survivors: Current Knowledge and Future Research Strategies. J Korean Acad Nurs 2017; 46:159-67. [PMID: 27182013 DOI: 10.4040/jkan.2016.46.2.159] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/31/2016] [Indexed: 11/09/2022]
Abstract
PURPOSE This article provides an overview of current knowledge on the impact of caregiving on the psychological and physical health of family caregivers of intensive care unit (ICU) survivors and suggestions for future research. METHODS Review of selected papers published in English between January 2000 and October 2015 reporting psychological and physical health outcomes in family caregivers of ICU survivors. RESULTS In family caregivers of ICU survivors followed up to five years after patients' discharge from an ICU, psychological symptoms, manifested as depression, anxiety and post-traumatic stress disorder, were highly prevalent. Poor self-care, sleep disturbances and fatigue were identified as common physical health problems in family caregivers. Studies to date are mainly descriptive; few interventions have targeted family caregivers. Further, studies that elicit unique needs of families from diverse cultures are lacking. CONCLUSION Studies to date have described the impact of caregiving on the psychological and physical health in family caregivers of ICU survivors. Few studies have tested interventions to support unique needs in this population. Therefore, evidence for best strategies is lacking. Future research is needed to identify ICU caregivers at greatest risk for distress, time points to target interventions with maximal efficacy, needs of those from diverse cultures and test interventions to mitigate family caregivers' burden.
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Affiliation(s)
- Jiyeon Choi
- Department of Acute & Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| | - Michael P Donahoe
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Leslie A Hoffman
- Department of Acute & Tertiary Care, School of Nursing & Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Ornstein KA, Aldridge MD, Garrido MM, Gorges R, Bollens-Lund E, Siu AL, Langa KM, Kelley AS. The Use of Life-Sustaining Procedures in the Last Month of Life Is Associated With More Depressive Symptoms in Surviving Spouses. J Pain Symptom Manage 2017; 53:178-187.e1. [PMID: 27864126 PMCID: PMC5253251 DOI: 10.1016/j.jpainsymman.2016.08.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/11/2016] [Accepted: 08/26/2016] [Indexed: 11/15/2022]
Abstract
CONTEXT Family caregivers of individuals with serious illness who undergo intensive life-sustaining medical procedures at the end of life may be at risk of negative consequences including depression. OBJECTIVES The objective of this study was to determine the association between patients' use of life-sustaining procedures at the end of life and depressive symptoms in their surviving spouses. METHODS We used data from the Health and Retirement Study, a longitudinal survey of U.S. residents, linked to Medicare claims data. We included married Medicare beneficiaries aged 65 years and older who died between 2000 and 2011 (n = 1258) and their surviving spouses. The use of life-sustaining procedures (i.e., intubation/mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral/parenteral nutrition, and cardiopulmonary resuscitation) in the last month of life was measured via claims data. Using propensity score matching, we compared change in depressive symptoms of surviving spouses. RESULTS Eighteen percent of decedents underwent one or more life-sustaining procedures in the last month of life. Those whose spouses underwent life-sustaining procedures had a 0.32-point increase in depressive symptoms after death (scale range = 0-8) and a greater likelihood of clinically significant depression (odds ratio = 1.51) compared with a matched sample of spouses of those who did not have procedures (P < 0.05). CONCLUSION Surviving spouses of those who undergo intensive life-sustaining procedures at the end of life experience a greater magnitude of increase in depressive symptoms than those whose spouses do not undergo such procedures. Further study of the circumstances and decision making surrounding these procedures is needed to understand their relationship with survivors' negative mental health consequences and how best to provide appropriate support.
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Affiliation(s)
- Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Melissa D Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Melissa M Garrido
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Rebecca Gorges
- Harris School of Public Policy, University of Chicago, Chicago, Illinois
| | - Evan Bollens-Lund
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Albert L Siu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Kenneth M Langa
- Department of Internal Medicine, Veterans Affairs Center for Clinical Management Research, Institute for Social Research, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
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New developments in the provision of family-centered care in the intensive care unit. Intensive Care Med 2017; 43:550-553. [PMID: 28124085 PMCID: PMC5359380 DOI: 10.1007/s00134-017-4684-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/10/2017] [Indexed: 11/15/2022]
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Torke AM, Monahan P, Callahan CM, Helft PR, Sachs GA, Wocial LD, Slaven JE, Montz K, Inger L, Burke ES. Validation of the Family Inpatient Communication Survey. J Pain Symptom Manage 2017; 53:96-108.e4. [PMID: 27720790 PMCID: PMC5191959 DOI: 10.1016/j.jpainsymman.2016.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 07/20/2016] [Accepted: 08/03/2016] [Indexed: 11/23/2022]
Abstract
CONTEXT Although many family members who make surrogate decisions report problems with communication, there is no validated instrument to accurately measure surrogate/clinician communication for older adults in the acute hospital setting. OBJECTIVES The objective of this study was to validate a survey of surrogate-rated communication quality in the hospital that would be useful to clinicians, researchers, and health systems. METHODS After expert review and cognitive interviewing (n = 10 surrogates), we enrolled 350 surrogates (250 development sample and 100 validation sample) of hospitalized adults aged 65 years and older from three hospitals in one metropolitan area. The communication survey and a measure of decision quality were administered within hospital days 3 and 10. Mental health and satisfaction measures were administered six to eight weeks later. RESULTS Factor analysis showed support for both one-factor (Total Communication) and two-factor models (Information and Emotional Support). Item reduction led to a final 30-item scale. For the validation sample, internal reliability (Cronbach's alpha) was 0.96 (total), 0.94 (Information), and 0.90 (Emotional Support). Confirmatory factor analysis fit statistics were adequate (one-factor model, comparative fit index = 0.981, root mean square error of approximation = 0.62, weighted root mean square residual = 1.011; two-factor model comparative fit index = 0.984, root mean square error of approximation = 0.055, weighted root mean square residual = 0.930). Total score and subscales showed significant associations with the Decision Conflict Scale (Pearson correlation -0.43, P < 0.001 for total score). Emotional Support was associated with improved mental health outcomes at six to eight weeks, such as anxiety (-0.19 P < 0.001), and Information was associated with satisfaction with the hospital stay (0.49, P < 0.001). CONCLUSION The survey shows high reliability and validity in measuring communication experiences for hospital surrogates. The scale has promise for measurement of communication quality and is predictive of important outcomes, such as surrogate satisfaction and well-being.
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Affiliation(s)
- Alexia M Torke
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA; IU Division of General Internal Medicine and Geriatrics, Indianapolis, Indiana, USA; Fairbanks Center for Medical Ethics, IU Health, Indianapolis, Indiana, USA; Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, Indiana, USA.
| | | | - Christopher M Callahan
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA; IU Division of General Internal Medicine and Geriatrics, Indianapolis, Indiana, USA
| | - Paul R Helft
- Fairbanks Center for Medical Ethics, IU Health, Indianapolis, Indiana, USA; IU Melvin and Bren Simon Cancer Center, Indianapolis, Indiana, USA
| | - Greg A Sachs
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA; IU Division of General Internal Medicine and Geriatrics, Indianapolis, Indiana, USA
| | - Lucia D Wocial
- Fairbanks Center for Medical Ethics, IU Health, Indianapolis, Indiana, USA
| | - James E Slaven
- IU Department of Biostatistics, Indianapolis, Indiana, USA
| | - Kianna Montz
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Lev Inger
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Emily S Burke
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
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Hutchison PJ, McLaughlin K, Corbridge T, Michelson KN, Emanuel L, Sporn PHS, Crowley-Matoka M. Dimensions and Role-Specific Mediators of Surrogate Trust in the ICU. Crit Care Med 2016; 44:2208-2214. [PMID: 27513360 PMCID: PMC5219932 DOI: 10.1097/ccm.0000000000001957] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In the ICU, discussions between clinicians and surrogate decision makers are often accompanied by conflict about a patient's prognosis or care plan. Trust plays a role in limiting conflict, but little is known about the determinants of trust in the ICU. We sought to identify the dimensions of trust and clinician behaviors conducive to trust formation in the ICU. DESIGN Prospective qualitative study. SETTING Medical ICU of a major urban university hospital. SUBJECTS Surrogate decision makers of intubated, mechanically ventilated patients in the medical ICU. MEASUREMENTS AND MAIN RESULTS Semistructured interviews focused on surrogates' general experiences in the ICU and on their trust in the clinicians caring for the patient. Interviews were audio-recorded, transcribed verbatim, and coded by two reviewers. Constant comparison was used to identify themes pertaining to trust. Thirty surrogate interviews revealed five dimensions of trust in ICU clinicians: technical competence, communication, honesty, benevolence, and interpersonal skills. Most surrogates emphasized the role of nurses in trust formation, frequently citing their technical competence. Trust in physicians was most commonly related to honesty and the quality of their communication with surrogates. CONCLUSIONS Interventions to improve trust in the ICU should be role-specific, since surrogate expectations are different for physicians and nurses with regard to behaviors relevant to trust. Further research is needed to confirm our findings and explore the impact of trust modification on clinician-family conflict.
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Affiliation(s)
- Paul J Hutchison
- 1Division of Pulmonary and Critical Care, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL.2Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL.3Division of Pulmonary and Critical Care, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.4Division of Critical Care Medicine, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL.5Buehler Center on Aging, Health & Society, Feinberg School of Medicine, Northwestern University, Chicago, IL.6Center for Bioethics and Medical Humanities, Feinberg School of Medicine, Northwestern University, Chicago, IL.7Jesse Brown Veterans Affairs Medical Center, Department of Medicine, Chicago, IL
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Turnbull AE, Sahetya SK, Needham DM. Aligning critical care interventions with patient goals: A modified Delphi study. Heart Lung 2016; 45:517-524. [PMID: 27593494 PMCID: PMC5887162 DOI: 10.1016/j.hrtlng.2016.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/28/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To develop a list of non-emergent, potentially harmful interventions commonly performed in ICUs that require a clear understanding of patients' treatment goals. BACKGROUND A 2016 policy statement from the American Thoracic Society and American College of Critical Care Medicine calls on intensivists to engage in shared decision-making when "making major treatment decisions that may be affected by personal values, goals, and preferences." METHODS A three-round modified Delphi consensus process was conducted via a panel of 6 critical care physicians, 6 ICU nurses, 6 former ICU patients, and 6 family members from 6 academic and community-based medical institutions in the U.S. mid-Atlantic region. RESULTS Recommendations about 8 interventions achieved consensus among respondents. CONCLUSIONS Clinical and patient/family participants in a modified Delphi consensus process were able to identify preference-sensitive decisions that should trigger clinicians to clarify patient goals and consider initiating shared decision-making.
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Affiliation(s)
- Alison E Turnbull
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Sarina K Sahetya
- Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses. JAMA Intern Med 2016; 176:1095-102. [PMID: 27367547 PMCID: PMC5470549 DOI: 10.1001/jamainternmed.2016.1200] [Citation(s) in RCA: 228] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Efforts to improve end-of-life care have focused primarily on patients with cancer. High-quality end-of-life care is also critical for patients with other illnesses. OBJECTIVE To compare patterns of end-of-life care and family-rated quality of care for patients dying with different serious illnesses. DESIGN, SETTING, AND PARTICIPANTS A retrospective cross-sectional study was conducted in all 146 inpatient facilities within the Veteran Affairs health system among patients who died in inpatient facilities between October 1, 2009, and September 30, 2012, with clinical diagnoses categorized as end-stage renal disease (ESRD), cancer, cardiopulmonary failure (congestive heart failure or chronic obstructive pulmonary disease), dementia, frailty, or other conditions. Data analysis was conducted from April 1, 2014, to February 10, 2016. MAIN OUTCOMES AND MEASURES Palliative care consultations, do-not-resuscitate orders, death in inpatient hospices, death in the intensive care unit, and family-reported quality of end-of-life care. RESULTS Among 57 753 decedents, approximately half of the patients with ESRD, cardiopulmonary failure, or frailty received palliative care consultations (adjusted proportions, 50.4%, 46.7%, and 43.7%, respectively) vs 73.5% of patients with cancer and 61.4% of patients with dementia (P < .001). Approximately one-third of patients with ESRD, cardiopulmonary failure, or frailty (adjusted proportions, 32.3%, 34.1%, and 35.2%, respectively) died in the intensive care unit, more than double the rates among patients with cancer and those with dementia (13.4% and 8.9%, respectively) (P < .001). Rates of excellent quality of end-of-life care reported by 34 005 decedents' families were similar for patients with cancer and those with dementia (adjusted proportions, 59.2% and 59.3%; P = .61), but lower for patients with ESRD, cardiopulmonary failure, or frailty (54.8%, 54.8%, and 53.7%, respectively; all P ≤ .02 vs patients with cancer). This quality advantage was mediated by palliative care consultation, setting of death, and a code status of do-not-resuscitate; adjustment for these variables rendered the association between diagnosis and overall end-of-life care quality nonsignificant. CONCLUSIONS AND RELEVANCE Family-reported quality of end-of-life care was significantly better for patients with cancer and those with dementia than for patients with ESRD, cardiopulmonary failure, or frailty, largely owing to higher rates of palliative care consultation and do-not-resuscitate orders and fewer deaths in the intensive care unit among patients with cancer and those with dementia. Increasing access to palliative care and goals of care discussions that address code status and preferred setting of death, particularly for patients with end-organ failure and frailty, may improve the overall quality of end-of-life care for Americans dying of these illnesses.
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Affiliation(s)
- Melissa W Wachterman
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts2Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer
| | - Corey Pilver
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts5Tufts Health Plan, Watertown, Massachusetts
| | - Dawn Smith
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Mary Ersek
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania7University of Pennsylvania School of Nursing, Philadelphia
| | - Stuart R Lipsitz
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nancy L Keating
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts8Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Wintermann GB, Weidner K, Strauß B, Rosendahl J, Petrowski K. Predictors of posttraumatic stress and quality of life in family members of chronically critically ill patients after intensive care. Ann Intensive Care 2016; 6:69. [PMID: 27439709 PMCID: PMC4954797 DOI: 10.1186/s13613-016-0174-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 07/07/2016] [Indexed: 12/22/2022] Open
Abstract
Background Prolonged mechanical ventilation for acute medical conditions increases the risk of chronic critical illness (CCI). Close family members are confronted with the life-threatening condition of the CCI patients and are prone to develop posttraumatic stress disorder affecting their health-related quality of life (HRQL). Main aim of the present study was to investigate patient- and family-related risk factors for posttraumatic stress and decreased HRQL in family members of CCI patients. Methods In a cross-sectional design nested within a prospective longitudinal cohort study, posttraumatic stress symptoms and quality of life were assessed in family members of CCI patients (n = 83, aged between 18 and 72 years) up to 6 months after transfer from ICU at acute care hospital to post-acute rehabilitation. Patients admitted a large rehabilitation hospital for ventilator weaning. The Posttraumatic Stress Scale-10 and the Euro-Quality of life-5D-3L were applied in both patients and their family members via telephone interview. Results A significant proportion of CCI patients and their family members (14.5 and 15.7 %, respectively) showed clinically relevant scores of posttraumatic stress. Both CCI patients and family members reported poorer HRQL than a normative sample. Factors independently associated with posttraumatic stress in family members were the time following ICU discharge (β = .256, 95 % confidence interval .053–.470) and the patients’ diagnosis of PTSD (β = .264, 95 % confidence interval .045–.453). Perceived satisfaction with the relationship turned out to be a protective factor for posttraumatic stress in family members of CCI patients (β = −.231, 95 % confidence interval −.423 to −.015). Regarding HRQL in family members, patients’ acute posttraumatic stress at ICU (β = −.290, 95 % confidence interval −.360 to −.088) and their own posttraumatic stress 3 to 6 months post-transfer (β = −.622, 95 % confidence interval −.640 to −.358) turned out to be significant predictors. Conclusions Posttraumatic stress and HRQL should be routinely assessed in family members of CCI patients at regular intervals starting early at ICU. Preventive family-centered interventions are needed to improve posttraumatic stress and HRQL in both patients and their family members. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0174-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gloria-Beatrice Wintermann
- Department of Psychotherapy and Psychosomatic Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Center for Sepsis Control and Care, Jena University Hospital, Friedrich-Schiller University, Jena, Germany.,Institute of Psychosocial Medicine and Psychotherapy, Jena University Hospital, Friedrich-Schiller University, Stoystr. 3, 07743, Jena, Germany
| | - Kerstin Weidner
- Department of Psychotherapy and Psychosomatic Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Bernhard Strauß
- Institute of Psychosocial Medicine and Psychotherapy, Jena University Hospital, Friedrich-Schiller University, Stoystr. 3, 07743, Jena, Germany
| | - Jenny Rosendahl
- Institute of Psychosocial Medicine and Psychotherapy, Jena University Hospital, Friedrich-Schiller University, Stoystr. 3, 07743, Jena, Germany.
| | - Katja Petrowski
- Department of Workplace Health Promotion, German Sport University Cologne, Cologne, Germany.
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Köse I, Zincircioğlu Ç, Öztürk YK, Çakmak M, Güldoğan EA, Demir HF, Şenoglu N, Erbay RH, Gonullu M. Factors Affecting Anxiety and Depression Symptoms in Relatives of Intensive Care Unit Patients. J Intensive Care Med 2016; 31:611-7. [DOI: 10.1177/0885066615595791] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/23/2015] [Indexed: 11/16/2022]
Abstract
Aim: To determine the incidences of anxiety and depression in relatives of patients admitted to an intensive care unit (ICU) and to investigate the relationships between psychological symptoms and demographic features of the patients and their relatives. Methodology: Relatives of 78 ICU patients were enrolled in the study. Sociodemographic features of patients and their relatives were recorded. The Turkish version of the Hospital Anxiety and Depression Scale was used to assess anxiety and depression. Results: Twenty-eight (35.9%) cases with anxiety and 56 (71.8%) cases with depression were identified. The mean anxiety and depression scores were 9.49 ± 4.183 and 9.40 ± 4.286, respectively. Anxiety ( P = .028) and concomitant anxiety with depression ( P = .035) were more frequent among family members of young patients. The relationship to the patient, especially being a spouse, was significantly associated with symptoms (anxiety, P = .009; depression, P = .019; and both, P = .005). Conclusion: Spouses and family members of relatively young patients had higher rates of anxiety and depression. In contrast to the literature, depression was more common than anxiety among the relatives of ICU patients. Further research is needed on the impact of cultural and regional differences on anxiety and depression rates in family members of ICU patients.
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Affiliation(s)
- Işıl Köse
- Department of Anesthesiology and Reanimation, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Çiler Zincircioğlu
- Department of Anesthesiology and Reanimation, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Yasemin Kılıç Öztürk
- Department of Family Medicine, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Meltem Çakmak
- Department of Anesthesiology and Reanimation, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | | | - Hafize Fisun Demir
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Balıkesir University, Balıkesir, Turkey
| | - Nimet Şenoglu
- Department of Anesthesiology and Reanimation, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Rıza Hakan Erbay
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Pamukkale University, Denizli, Turkey
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Berry M, Brink E, Metaxa V. Time for change? A national audit on bereavement care in intensive care units. J Intensive Care Soc 2016; 18:11-16. [PMID: 28979531 DOI: 10.1177/1751143716653770] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Bereaved ICU family members frequently experience anxiety, depression and post-traumatic stress disorder, which have been associated with significantly impaired quality of life. Recognising that their needs extend beyond the support provided by their friends and family, the Intensive Care Society had published in 1998 recommendations around bereavement care. OBJECTIVE The aim of the present national audit was to compare bereavement services in England against the nine recommendations set out by the Intensive Care Society guidelines. METHODS A telephone audit was carried out in all adult ICUs in England. RESULTS A total of 144 NHS Trusts (179 ICUs) met the inclusion criteria and 113 responses were collected (78% of Trusts, 63% of individual ICUs). Although most ICUs provided administrative information (96% had an information booklet), training (53%), auditing (19%) and adequate facilities (27%) did not meet the recommended standards. CONCLUSION Bereavement care is underdeveloped in English ICUs. This important but underreported topic should be prioritised in the critical care research agenda.
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Affiliation(s)
- M Berry
- Imperial School of Anaesthesia, London, UK
| | - E Brink
- King's College Hospital, London, UK
| | - V Metaxa
- King's College Hospital, London, UK
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Perkins E, Gambles M, Houten R, Harper S, Haycox A, O’Brien T, Richards S, Chen H, Nolan K, Ellershaw JE. The care of dying people in nursing homes and intensive care units: a qualitative mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04200] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn England and Wales the two most likely places of death are hospitals (52%) and nursing homes (22%). The Department of Health published its National End of Life Care Strategy in July 2008 (Department of Health.End of Life Care Strategy: Promoting High Quality Care For All Adults at the End of Life. London: Department of Health; 2008) to improve the provision of care, recommending the use of the Liverpool Care Pathway for the Dying Patient (LCP).AimThe original aim was to assess the impact of the LCP on care in two settings: nursing homes and intensive care units (ICUs).DesignQualitative, matched case study.MethodsData were collected from 12 ICUs and 11 nursing homes in England: (1) documentary analysis of provider end-of-life care policy documents; (2) retrospective analysis of 10 deaths in each location using written case notes; (3) interviews with staff about end-of-life care; (4) observation of the care of dying patients; (5) analysis of the case notes pertaining to the observed patient’s death; (6) interview with a member of staff providing care during the observed period; (7) interview with a bereaved relative present during the observation; (8) economic analysis focused on the observed patients; and (9) strict inclusion and selection criteria for nursing homes and ICUs applied to match sites on LCP use/non-LCP use.ResultsIt was not possible to meet the stated aims of the study. Although 23 sites were recruited, observations were conducted in only 12 sites (eight using the LCP). A robust comparison on the basis of LCP use could not, therefore, take place. Although nurses in both settings reported that the LCP supported good care, the LCP was interpreted and used differently across sites, with the greatest variation in ICUs. Although not able to address the original research question, this study provides an unprecedented insight into care at the end of life in two different settings. The majority of nursing homes had implemented some kind of ‘pathway’ for dying patients and most homes participating in the observational stage were using the LCP. However, training in care of the dying was variable and specific issues were identified relating to general practitioner involvement, the use of anticipatory drugs and the assessment of consciousness and the swallowing reflex. In ICUs, end-of-life care was inextricably linked with the withdrawal of active treatment and controlling the pace of death. The data highlight how the decision to withdraw was made and, importantly, how relatives were involved in this process. The fact that most patients died soon after the withdrawal of interventions was reported to limit the appropriateness of the LCP in this setting.LimitationsAlthough the recruitment of matched sites was achieved, variable site participation resulted in a skewed sample. Issues with the sample size and a blurring of LCP use and non-use limit the extent to which the ambitious aims of the study were achieved.ConclusionsThis study makes a unique contribution to understanding the complexity of care at the end of life in two very different settings. More research is needed into the ways in which an organisational culture can be created within which the principles of good end-of-life care become translated into practice.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Elizabeth Perkins
- Health and Community Care Research Unit, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Maureen Gambles
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Rachel Houten
- Management School, University of Liverpool, Liverpool, UK
| | - Sheila Harper
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Alan Haycox
- Management School, University of Liverpool, Liverpool, UK
| | - Terri O’Brien
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Sarah Richards
- Management School, University of Liverpool, Liverpool, UK
| | - Hong Chen
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Kate Nolan
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - John E Ellershaw
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Akroute AR, Bondas T. Critical care nurses and relatives of elderly patients in intensive care unit–Ambivalent interaction. Intensive Crit Care Nurs 2016; 34:59-72. [DOI: 10.1016/j.iccn.2015.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 07/19/2015] [Accepted: 08/07/2015] [Indexed: 12/31/2022]
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Downey L, Hayduk LA, Curtis JR, Engelberg RA. Measuring Depression-Severity in Critically Ill Patients' Families with the Patient Health Questionnaire (PHQ): Tests for Unidimensionality and Longitudinal Measurement Invariance, with Implications for CONSORT. J Pain Symptom Manage 2016; 51:938-46. [PMID: 26706625 PMCID: PMC4875822 DOI: 10.1016/j.jpainsymman.2015.12.303] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 12/02/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT Families of intensive care unit patients are at risk for depression and are important targets for depression-reducing interventions. Multi-item scores for evaluating such interventions should meet criteria for unidimensionality and longitudinal measurement invariance. The Patient Health Questionnaire (PHQ), widely used for measuring depression severity, provides standard nine-, eight-, and two-item scores. However, published studies often report no (or weak) evidence of these scores' unidimensionality/invariance, and no tests have evaluated them as measures of depression severity in intensive care unit patients' families. OBJECTIVES To identify multi-item PHQ constructs with promise for evaluating change in depression severity among family members of critically ill patients. METHODS Structural equation models with rigorous fit criterion (χ(2), P ≥ 0.05) tested the standard nine-, eight-, and two-item PHQ, and other item subsets, for unidimensionality and longitudinal invariance, using data from a trial evaluating an intervention to reduce depressive symptoms in family members. RESULTS Neither the standard nine-item nor the eight-item PHQ construct showed longitudinal invariance, although the standard two-item construct and other item subsets did. CONCLUSION The longer eight- and nine-item PHQ scores appear inappropriate for assessing depression severity in this population, with constructs based on smaller subsets of items being more promising targets for future trials. The Consolidated Standards of Reporting Trials requirement for prespecified trial outcomes is problematic because unidimensionality/invariance testing must occur after trial completion. Consolidated Standards of Reporting Trials could be strengthened by endorsing rigorous assessment of composite scores and encouraging use of the most appropriate substitute, should trial-based evidence challenge the legitimacy of prespecified multi-item scores.
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Affiliation(s)
- Lois Downey
- Division of Pulmonary and Critical Care, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA.
| | - Leslie A Hayduk
- Department of Sociology, University of Alberta, Edmonton, Alberta, Canada
| | - J Randall Curtis
- Division of Pulmonary and Critical Care, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary and Critical Care, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
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Roger C, Beloucif S. Communication with patient's families in the intensive care unit: Do we really meet their needs? Anaesth Crit Care Pain Med 2016; 35:179-81. [PMID: 27118400 DOI: 10.1016/j.accpm.2016.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Claire Roger
- Intensive care unit, department of anesthesiology, critical care, pain and emergency medicine, Nîmes university hospital, place du Pr Debré, 30029 Nîmes, France.
| | - Sadek Beloucif
- Department of anesthesiology and critical care medicine, université Paris 13, Avicenne university hospital, Sorbonne Paris-Cité, 93000 Paris, France
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135
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McAdam JL, Erikson A. Bereavement Services Offered in Adult Intensive Care Units in the United States. Am J Crit Care 2016; 25:110-7. [PMID: 26932912 DOI: 10.4037/ajcc2016981] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Losing a loved one in the intensive care unit (ICU) is stressful for family members. Providing bereavement support to them is recommended. However, little is known about the prevalence of bereavement services implemented in adult ICUs. OBJECTIVE To describe current bereavement follow-up services in adult ICUs. METHOD A cross-sectional prospective study design was used. ICU nurse leaders completed a 26-item online survey posted in the American Association of Critical-Care Nurses e-newsletter. The survey contained questions about current practices in bereavement care. Data were collected for 1 month and were analyzed by using descriptive statistics and binary logistic regression. RESULTS A total of 237 ICU nurse leaders responded to the survey. Hospital and ICU types were diverse, with most being community (n = 81, 34.2%) and medical (n = 61, 25.7%). Most respondents reported that their ICUs (n = 148, 62.4%) did not offer bereavement follow-up services, and many barriers were noted. When bereavement follow-up care was offered, it was mainly informal (eg, condolence cards, brochures). Multiple logistic regression indicated that ICUs in hospitals with palliative care were almost 8 times (odds ratio, 7.66) more likely to provide bereavement support than were ICUs in hospitals without palliative care. CONCLUSIONS The study findings provide insight into what type of bereavement evaluation methods are being used, what barriers are present that hinder use of bereavement follow-up services, and potential interventions to overcome those barriers in adult ICUs in the United States.
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Affiliation(s)
- Jennifer L. McAdam
- Jennifer L. McAdam is an associate professor, Samuel Merritt University, School of Nursing, Oakland, California. Alyssa Erikson is an assistant professor, California State University, Monterey Bay, Seaside, California
| | - Alyssa Erikson
- Jennifer L. McAdam is an associate professor, Samuel Merritt University, School of Nursing, Oakland, California. Alyssa Erikson is an assistant professor, California State University, Monterey Bay, Seaside, California
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Probst DR, Gustin JL, Goodman LF, Lorenz A, Wells-Di Gregorio SM. ICU versus Non-ICU Hospital Death: Family Member Complicated Grief, Posttraumatic Stress, and Depressive Symptoms. J Palliat Med 2016; 19:387-93. [PMID: 26828564 DOI: 10.1089/jpm.2015.0120] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Family members of patients who die in an ICU are at increased risk of psychological sequelae compared to those who experience a death in hospice. OBJECTIVE This study explored differences in rates and levels of complicated grief (CG), posttraumatic stress disorder (PTSD), and depression between family members of patients who died in an ICU versus a non-ICU hospital setting. Differences in family members' most distressing experiences at the patient's end of life were also explored. METHODS The study was an observational cohort. Subjects were next of kin of 121 patients who died at a large, Midwestern academic hospital; 77 died in the ICU. Family members completed measures of CG, PTSD, depression, and end-of-life experiences. RESULTS Participants were primarily Caucasian (93%, N = 111), female (81%, N = 98), spouses (60%, N = 73) of the decedent, and were an average of nine months post-bereavement. Forty percent of family members met the Inventory of Complicated Grief CG cut-off, 31% met the Impact of Events Scale-Revised PTSD cut-off, and 51% met the Center for Epidemiologic Studies Depression Scale depression cut-off. There were no significant differences in rates or levels of CG, PTSD, or depressive symptoms reported by family members between hospital settings. Several distressing experiences were ranked highly by both groups, but each setting presented unique distressing experiences for family members. CONCLUSIONS Psychological distress of family members did not differ by hospital setting, but the most distressing experiences encountered at end of life in each setting highlight potentially unique interventions to reduce distress post-bereavement for family members.
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Affiliation(s)
- Danielle R Probst
- 1 Department of Psychiatry, Division of Palliative Medicine, Wexner Medical Center, The Ohio State University , Columbus, Ohio.,2 Department of Internal Medicine, Division of Palliative Medicine, Wexner Medical Center, The Ohio State University , Columbus, Ohio
| | - Jillian L Gustin
- 2 Department of Internal Medicine, Division of Palliative Medicine, Wexner Medical Center, The Ohio State University , Columbus, Ohio
| | - Lauren F Goodman
- 2 Department of Internal Medicine, Division of Palliative Medicine, Wexner Medical Center, The Ohio State University , Columbus, Ohio
| | - Amanda Lorenz
- 2 Department of Internal Medicine, Division of Palliative Medicine, Wexner Medical Center, The Ohio State University , Columbus, Ohio
| | - Sharla M Wells-Di Gregorio
- 1 Department of Psychiatry, Division of Palliative Medicine, Wexner Medical Center, The Ohio State University , Columbus, Ohio.,2 Department of Internal Medicine, Division of Palliative Medicine, Wexner Medical Center, The Ohio State University , Columbus, Ohio
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137
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Hagerty TA, Velázquez Á, Schmidt JM, Falo C. Assessment of satisfaction with care and decision-making among English and Spanish-speaking family members of neuroscience ICU patients. Appl Nurs Res 2016; 29:262-7. [DOI: 10.1016/j.apnr.2015.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 01/28/2015] [Accepted: 02/02/2015] [Indexed: 01/17/2023]
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138
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Grudzen CR, Emlet LL, Kuntz J, Shreves A, Zimny E, Gang M, Schaulis M, Schmidt S, Isaacs E, Arnold R. EM Talk: communication skills training for emergency medicine patients with serious illness. BMJ Support Palliat Care 2016; 6:219-24. [PMID: 26762163 DOI: 10.1136/bmjspcare-2015-000993] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 12/17/2015] [Indexed: 11/03/2022]
Abstract
The emergency department visit for a patient with serious illness represents a sentinel event, signalling a change in the illness trajectory. By better understanding patient and family wishes, emergency physicians can reinforce advance care plans and ensure the hospital care provided matches the patient's values. Despite their importance in care at the end of life, emergency physicians have received little training on how to talk to seriously ill patients and their families about goals of care. To expand communication skills training to emergency medicine, we developed a programme to give emergency medicine physicians the ability to empathically deliver serious news and to talk about goals of care. We have built on lessons from prior studies to design an intervention employing the most effective pedagogical techniques, including the use of simulated patients/families, role-playing and small group learning with constructive feedback from master clinicians. Here, we describe our evidence-based communication skills training course EM Talk using simulation, reflective feedback and deliberate practice.
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Affiliation(s)
- Corita R Grudzen
- Ronald O Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York, New York, USA
| | - Lillian L Emlet
- Department of Critical Care Medicine and Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joanne Kuntz
- Department of Traumatology and Emergency Medicine, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Ashley Shreves
- Department of Emergency Medicine, Mount Sinai Medical Center, New York, New York, USA
| | - Erin Zimny
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - Maureen Gang
- Ronald O Perelman Department of Emergency Medicine and Population Health, New York University School of Medicine, New York, New York, USA
| | - Monique Schaulis
- Department of Emergency Medicine, Kaiser Permanente Health System, San Francisco, California, USA
| | - Scott Schmidt
- Department of Emergency Medicine, Kaiser Permanente, San Raphael, California, USA
| | - Eric Isaacs
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Robert Arnold
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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139
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Kon AA, Davidson JE, Morrison W, Danis M, White DB. Shared Decision Making in ICUs: An American College of Critical Care Medicine and American Thoracic Society Policy Statement. Crit Care Med 2016; 44:188-201. [PMID: 26509317 PMCID: PMC4788386 DOI: 10.1097/ccm.0000000000001396] [Citation(s) in RCA: 313] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Shared decision making is endorsed by critical care organizations; however, there remains confusion about what shared decision making is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define shared decision making, recommend when shared decision making should be used, identify the range of ethically acceptable decision-making models, and present important communication skills. DESIGN The American College of Critical Care Medicine and American Thoracic Society Ethics Committees reviewed empirical research and normative analyses published in peer-reviewed journals to generate recommendations. Recommendations approved by consensus of the full Ethics Committees of American College of Critical Care Medicine and American Thoracic Society were included in the statement. MAIN RESULTS Six recommendations were endorsed: 1) DEFINITION: Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient's values, goals, and preferences. 2) Clinicians should engage in a shared decision making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences. 3) Clinicians should use as their "default" approach a shared decision making process that includes three main elements: information exchange, deliberation, and making a treatment decision. 4) A wide range of decision-making approaches are ethically supportable, including patient- or surrogate-directed and clinician-directed models. Clinicians should tailor the decision-making process based on the preferences of the patient or surrogate. 5) Clinicians should be trained in communication skills. 6) Research is needed to evaluate decision-making strategies. CONCLUSIONS Patient and surrogate preferences for decision-making roles regarding value-laden choices range from preferring to exercise significant authority to ceding such authority to providers. Clinicians should adapt the decision-making model to the needs and preferences of the patient or surrogate.
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Affiliation(s)
- Alexander A. Kon
- Naval Medical Center San Diego, San Diego, CA
- University of California San Diego, San Diego, CA
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140
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Miller JJ, Morris P, Files DC, Gower E, Young M. Decision conflict and regret among surrogate decision makers in the medical intensive care unit. J Crit Care 2015; 32:79-84. [PMID: 26810482 DOI: 10.1016/j.jcrc.2015.11.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/30/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Family members of critically ill patients in the intensive care unit face significant morbidity. It may be the decision-making process that plays a significant role in the psychological morbidity associated with being a surrogate in the ICU. We hypothesize that family members facing end-of-life decisions will have more decisional conflict and decisional regret than those facing non-end-of-life decisions. METHODS We enrolled a sample of adult patients and their surrogates in a tertiary care, academic medical intensive care unit. We queried the surrogates regarding decisions they had made on behalf of the patient and assessed decision conflict. We then contacted the family member again to assess decision regret. RESULTS Forty (95%) of 42 surrogates were able to identify at least 1 decision they had made on behalf of the patient. End-of-life decisions (defined as do not resuscitate [DNR]/do not intubate [DNI] or continuation of life support) accounted for 19 of 40 decisions (47.5%). Overall, the average Decision Conflict Scale (DCS) score was 21.9 of 100 (range 0-100, with 0 being little decisional conflict and 100 being great decisional conflict). The average DCS score for families facing end-of-life decisions was 25.5 compared with 18.7 for all other decisions. Those facing end-of-life decisions scored higher on the uncertainty subscale (subset of DCS questions that indicates level of certainty regarding decision) with a mean score of 43.4 compared with all other decisions with a mean score of 27.0. Overall, very few surrogates experienced decisional regret with an average DRS score of 13.4 of 100. CONCLUSIONS Nearly all surrogates enrolled were faced with decision-making responsibilities on behalf of his or her critically ill family member. In our small pilot study, we found more decisional conflict in those surrogates facing end-of-life decisions, specifically on the subset of questions dealing with uncertainty. Surrogates report low levels of decisional regret.
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Affiliation(s)
- Jesse J Miller
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
| | - Peter Morris
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
| | - D Clark Files
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
| | - Emily Gower
- Wake Forest School of Medicine, Department of Epidemiology and Ophthalmology, Winston Salem, NC 27012.
| | - Michael Young
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
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141
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Kayser JB. Mediation Training for the Physician: Expanding the Communication Toolkit to Manage Conflict. THE JOURNAL OF CLINICAL ETHICS 2015. [DOI: 10.1086/jce2015264339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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142
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Patel D, Cohen ED, Barnato AE. The effect of framing on surrogate optimism bias: A simulation study. J Crit Care 2015; 32:85-8. [PMID: 26796950 DOI: 10.1016/j.jcrc.2015.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 10/06/2015] [Accepted: 11/18/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To explore the effect of emotion priming and physician communication behaviors on optimism bias. MATERIALS AND METHODS We conducted a 5 × 2 between-subject randomized factorial experiment using a Web-based interactive video designed to simulate a family meeting for a critically ill spouse/parent. Eligibility included age at least 35 years and self-identifying as the surrogate for a spouse/parent. The primary outcome was the surrogate's election of code status. We defined optimism bias as the surrogate's estimate of prognosis with cardiopulmonary resuscitation (CPR) > their recollection of the physician's estimate. RESULTS Of 373 respondents, 256 (69%) logged in and were randomized and 220 (86%) had nonmissing data for prognosis. Sixty-seven (30%) of 220 overall and 56 of (32%) 173 with an accurate recollection of the physician's estimate had optimism bias. Optimism bias correlated with choosing CPR (P < .001). Emotion priming (P = .397), physician attention to emotion (P = .537), and framing of CPR as the social norm (P = .884) did not affect optimism bias. Framing the decision as the patient's vs the surrogate's (25% vs 36%, P = .066) and describing the alternative to CPR as "allow natural death" instead of "do not resuscitate" (25% vs 37%, P = .035) decreased optimism bias. CONCLUSIONS Framing of CPR choice during code status conversations may influence surrogates' optimism bias.
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Affiliation(s)
- Dev Patel
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Elan D Cohen
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
| | - Amber E Barnato
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA; Section of Decision Sciences, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Health Policy and Management, Pitt Public Health, University of Pittsburgh, Pittsburgh, PA.
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Prochaska MT, Sulmasy DP. Recommendations to Surrogates at the End of Life: A Critical Narrative Review of the Empirical Literature and a Normative Analysis. J Pain Symptom Manage 2015; 50:693-700. [PMID: 26025276 DOI: 10.1016/j.jpainsymman.2015.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 05/11/2015] [Accepted: 05/21/2015] [Indexed: 11/17/2022]
Abstract
Physician recommendations have historically been a part of shared decision making. Recent literature has challenged the idea that physician recommendations should be part of shared decision making at the end of life, particularly the making of recommendations to surrogates of incapacitated patients. Close examination of the studies and the available data on surrogate preferences for decisional authority at the end of life, however, provide an empirical foundation for a style of shared decision making that includes a physician recommendation. Moreover, there are independent ethical reasons for arguing that physician recommendations enhance rather than detract from shared decision making.
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Affiliation(s)
- Micah T Prochaska
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Daniel P Sulmasy
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA; MacLean Center for Clinical and Medical Ethics, The University of Chicago, Chicago, Illinois, USA; The Divinity School, The University of Chicago, Chicago, Illinois, USA.
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144
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Ratliff M, Neumann JO. [Decision conflicts with relatives in the intensive care unit]. Med Klin Intensivmed Notfmed 2015; 111:638-643. [PMID: 26514821 DOI: 10.1007/s00063-015-0109-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 07/25/2015] [Accepted: 08/02/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND If medicine is coming close to its limits conflicts sometimes occur. Most conflicts in the intensive care unit (ICU) involve the medical team and patients' relatives. In particular decisions about withholding and withdrawing life-sustaining therapy lead to conflicts. Decisions about limiting life-sustaining treatment are burdened by conflicts and put an enormous strain particularly on relatives. AIM Illustration of currently available studies and existing recommendations on how to manage potentially conflict-laden decision-finding discussions on the ICU are presented. MATERIAL AND METHODS This article is based on a selective literature research in the PubMed database. RESULTS Studies have been carried out to evaluate posttraumatic stress disorders in relatives who were involved in life-limiting treatment decisions. Conflicts on the ICU put an emotional strain on relatives. Evidence-based recommendations are available regarding physicians' attitudes during discussions about therapy decisions, communication style and other contextual factors. Study results show that the emotional stress level relatives have to endure can be reduced if conversations between patients' families and the clinical personnel were conducted according to these recommendations. The involvement of a clinical ethics committee can prevent conflicts and has been shown to have no impact on the mortality rate but does decrease the time life-sustaining measures were unsuccessfully pursued. CONCLUSION To prevent conflicts between the medical personnel and patients' relatives on the ICU, a timely, congruent and empathic conversation style in an appropriate, quiet environment is essential. Consultation with clinical ethics committees is recommended to de-escalate disputes.
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Affiliation(s)
- M Ratliff
- Neurochirurgische Klinik Heidelberg, Universität Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - J-O Neumann
- Neurochirurgische Klinik Heidelberg, Universität Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
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Andresen M, Guic E, Orellana A, Diaz MJ, Castro R. Posttraumatic stress disorder symptoms in close relatives of intensive care unit patients: Prevalence data resemble that of earthquake survivors in Chile. J Crit Care 2015. [DOI: 10.1016/j.jcrc.2015.06.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Paul RG, Finney SJ. Family satisfaction with care on the ICU: essential lessons for all doctors. Br J Hosp Med (Lond) 2015; 76:504-9. [DOI: 10.12968/hmed.2015.76.9.504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Richard G Paul
- NIHR Clinical Research Fellow in Adult Intensive Care, Royal Brompton Hospital, London SW3 6NP
| | - Simon J Finney
- Consultant in Adult Intensive Care in the Adult Intensive Care Unit, Royal Brompton Hospital, London SW3 6NP
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Rueckriegel SM, Baron M, Domschke K, Neuderth S, Kunze E, Kessler AF, Nickl R, Westermaier T, Ernestus RI. Trauma- and distress-associated mental illness symptoms in close relatives of patients with severe traumatic brain injury and high-grade subarachnoid hemorrhage. Acta Neurochir (Wien) 2015; 157:1329-36; discussion 1336. [PMID: 26105760 DOI: 10.1007/s00701-015-2470-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 06/03/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Close relatives (CR) of patients with severe traumatic brain injury (TBI) and high-grade subarachnoid hemorrhage (SAH) suffer extraordinary distress during the treatment: Distress may lead to persisting mental illness symptoms within the spectrum of post-traumatic stress disorder (PTSD), anxiety disorders, and depression. The primary goal of this study was to determine the prevalence and severity of these symptoms in CR. The secondary goal was identification of associated factors. METHOD Standardized interviews were conducted with 53 CR (mean age of 57.7 ± 11.4 years) of patients with TBI °III (n = 27) and high-grade SAH H&H °III-V (n = 26) between 5 and 15 months after the event. The interviews contained a battery of surveys to quantify symptoms of PTSD, anxiety disorders, and depression, i.e., Impact of Event Scale (IES-R), 36-item Short-Form General Health Survey (SF-36), and Hospital Anxiety and Depression Scale (HADS). Fixed and modifiable possibly influencing factors were correlated. RESULTS Twenty-eight CR (53 %) showed IES-R scores indicating a probable diagnosis of PTSD. Twenty-five CR (47 %) showed an increased anxiety score and 18 (34 %) an increased depression score using HADS. Mean physical component summary of SF-36 was not abnormal (49.1 ± 9.1), whereas mean mental component summary was under average (41.0 ± 13.2), indicating a decreased quality of life caused by mental effects. Perception of the interaction quality with the medical staff and involvement into medical decisions correlated negatively with severity of mental illness symptoms. Evasive coping strategies were highly significantly associated with symptoms. CONCLUSIONS This study quantifies an extraordinarily high prevalence of mental illness symptoms in CR of patients with critical acquired brain injury due to SAH and TBI. Modifiable factors were associated with severity of mental illness symptoms. Prospective studies testing efficiency of early psychotherapeutic interventions are needed.
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Affiliation(s)
- Stefan Mark Rueckriegel
- Department of Neurosurgery, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg, Germany,
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149
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Kourti M, Christofilou E, Kallergis G. Anxiety and depression symptoms in family members of icu patients. AVANCES EN ENFERMERÍA 2015. [DOI: 10.15446/av.enferm.v33n1.48670] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
<p><strong>Objective:</strong> This study investigated symptoms of anxiety and depression in relatives of patients admitted in the Intensive Care Unit and determined whether these symptoms were associated to the seriousness of the patients’ condition.</p><p><strong>Metodology:</strong> A total of 102 patients’ relatives were surveyed<br />during the study. They were given a self-report questionnaire in order to assess demographic data, anxiety and depression symptoms. The symptoms of anxiety and depression were evaluated with the Hospital Anxiety and Depression Scale (hads). Patient’s condition was evaluated with a.p.a.ch.e ii Score.</p><p><strong>Results:</strong> More than 60% of patients’ relatives presented severe symptoms of anxiety and depression. No relation was found between symptoms of anxiety and depression of the relatives of patients and patients’ condition of health. On the<br />contrary, these feelings used to exist regardless of the seriousness of patient’s condition.</p><p><strong>Conclusions:</strong> The assessment of these patients is recommended in order serious problems of anxiety<br />and depression to be prevented. </p>
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Cai X, Robinson J, Muehlschlegel S, White DB, Holloway RG, Sheth KN, Fraenkel L, Hwang DY. Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units. Neurocrit Care 2015; 23:131-41. [PMID: 25990137 PMCID: PMC4816524 DOI: 10.1007/s12028-015-0149-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In the neuroscience intensive care unit (NICU), most patients lack the capacity to make their own preferences known. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preference-based treatment decisions, oftentimes in challenging situations where prognosis is uncertain. The neurointensivist has a large responsibility and role to play in this shared decision-making process. This review covers how NICU patient preferences are determined through existing advance care documentation or surrogate decision makers and how the optimum roles of the physician and surrogate decision maker are addressed. We outline the process of reaching a shared decision between family and care team and describe a practice for conducting optimum family meetings based on studies of ICU families in crisis. We review challenges in the decision-making process between surrogate decision makers and medical teams in neurocritical care settings, as well as methods to ameliorate conflicts. Ultimately, the goal of shared decision making is to increase knowledge amongst surrogates and care providers, decrease decisional conflict, promote realistic expectations and preference-centered treatment strategies, and lift the emotional burden on families of neurocritical care patients.
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Affiliation(s)
- Xuemei Cai
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA,
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